Polymorphonuclear leucocyte function tests: a comparison of cytochrome C reduction and flow cytometric analysis

Assay results were compared between the cytochrome C reduction test and flow cytometry using fluorescent beads or DCFH-DA (2', 7'-dichlorofluorescein diacetate) granules, in examining the phagocytosing and killing properties of polymorphonuclear leucocytes (PMN). When PMN samples from 20 healthy persons were assayed, no correlation was found between the cytochrome test and the phagocytosis (fluorescent beads) test or phagocytosing-killing (DCFH-DA) test by flow cytometry techniques. It is suggested that this might be caused by the fact that for technical reasons the two tests employed different stimulants and different substances to be phagocytosed. The simple flow cytometry procedure is now in widespread use as a PMN function test rather than the cytochrome C or nitroblue tetrazolium (NBT) dye reduction tests, and caution should be exercised in comparing and interpreting test results reported from separate laboratories. Because results using these two tests do not necessarily agree with each other, it seems preferable for PMN function testing to employ a combination of two or more approaches relying on different assay principles.

Subcutaneous seeding of small hepatocellular carcinoma after fine needle aspiration biopsy

Ultrasonically guided fine needle (21 gauge) aspiration biopsy (FNAB) was performed on a patient with a hepatocellular carcinoma (HCC) measuring 1.5 x 1.5 cm in segment VI of the liver. The tumour was located just beneath the liver surface. Subsegmentectomy of segment VI was performed. Twelve months after the biopsy and 10 months after the operation, levels of alpha-fetoprotein (AFP) and protein induced by Vitamin K absence or antagonist-II (PIVKA-II) increased gradually without any evidence of recurrence of HCC in the liver. Thirteen months after the biopsy, the patient palpated a hard subcutaneous nodule 1.5 cm in diameter in the right lower anterior chest wall at the insertion site of the biopsy needle. A subcutaneous tumour was excised and histological examination revealed moderately differentiated HCC. The levels of AFP and PIVKA-II normalized thereafter. These tumour markers were therefore useful for diagnosing the subcutaneous nodule as a metastatic HCC. The patient is currently doing well without further recurrence of HCC or needle-tract seeding 23 months after subsegmentectomy and 11 months after excision of the subcutaneous tumour.

Serum adenosine deaminase 2 and neopterin levels are increased in a majority of hemophiliacs irrespective of infection with human immunodeficiency virus type 1

We investigated serum levels of adenosine deaminase 2 (ADA2) and neopterin (NP) in hemophiliacs with or without infection with human immunodeficiency virus type 1 (HIV-1). The mean (+/- SD) serum ADA2 level in hemophiliacs positive for HIV-1 (45.2 +/- 17.6 U/L) and negative for HIV-1 (34.9 +/- 15.8 U/L) was significantly higher than that in healthy controls (12.0 +/- 7.0 U/L) (P < .01). The mean serum NP level was also higher in HIV-1-positive hemophiliacs (10.2 +/- 6.1 nmol/L) and HIV-1-negative hemophiliacs (7.0 +/- 2.9 nmol/L) than in the healthy controls (4.3 +/- 1.3 nmol/L). Although the HIV-1-positive hemophiliacs had higher mean ADA2 and NP levels than did hemophiliacs in the HIV-1-negative group (P < .01), the levels of most of the patients in both groups were similar. ADA2 and NP levels in serial samples from asymptomatic carriers and patients with stable AIDS showed no marked changes over a period of up to 6 years. These findings indicate that ADA2 and NP are not specific markers of HIV-1 infection in hemophiliacs. Nonspecific immunologic activation due to the repeated infusion of antihemophilic factor concentrate could be one cause for the increased serum levels of ADA2 and NP in hemophiliacs.

Tau protein kinase II is involved in the regulation of the normal phosphorylation state of tau protein

To study the phosphorylation state of tau in vivo, we have prepared antisera by immunizing rabbits with synthetic phosphopeptides containing phosphoamino acids at specific sites that are potential targets for tau protein kinase II. Immunoblot experiments using these antisera demonstrated that tau in microtubule-associated proteins is phosphorylated at Ser144 and at Ser315. Almost all tau variants separated on two-dimensional gel electrophoresis were phosphorylated at Ser144 and nearly one-half of them at Ser315. Phosphorylation at Ser144 and at Thr147 of tau isolated from heat-stable brain extracts was shown to be developmentally regulated, with the highest level of phosphorylation found at postnatal week 1. In vitro phosphorylation of tau by tau protein kinase I, a kinase responsible for abnormal phosphorylation of tau found in paired helical filaments of patients with Alzheimer's disease, was enhanced by prior phosphorylation of tau by tau protein kinase II. Thus, we suggest that tau protein kinase II is indirectly involved, at least in part, in the regulation of the phosphorylation state of tau in neuronal cells.

The treatment of intracapsular hip fractures with total hip arthroplasty in rheumatoid arthritis

Total hip arthroplasty was performed on 41 patients with rheumatoid arthritis for 43 intracapsular hip fractures from 1971 to 1989. Followup, observation of clinical signs, and radiographs were conducted between one to ten years. Of the 41 patients, 25 had died by the end of the study. Total hip arthroplasty was found to be effective in relieving joint pain, and the walking ability of patients generally recovered to pre-injury status following the operation. Some patients experienced deterioration of the knee and ankle joints due to rheumatoid arthritis, and in such cases there was progressive loss of walking ability. Nevertheless, the function of the hip joint was well preserved, and most patients reported that pain had disappeared and the joint range of motion had returned to normal. In only one case was revision surgery necessary. There was little overall loosening of prostheses, and there were no problems concerning the durability of the artificial joint. The presence, therefore, of femoral neck fractures in patients with rheumatoid arthritis, who are to be encouraged to get out of bed and begin walking as soon as possible, is a strong indication for total hip arthroplasty.

Stimulation of Cl- and HCO3- secretion by intramural cholinergic neurons in guinea pig antrum in vitro

Regulation of Cl- and HCO3- secretion by intramural cholinergic neurons was investigated in guinea pig antrum in vitro. Sheet preparations composed of the mucosa and the submucosa were mounted between Ussing chambers and bathed with buffer-free solution on the luminal surface and with HCO3(-)-CO2 solution on the serosal side. Short-circuit current (Isc), unidirectional fluxes of 36Cl and 22Na, and the luminal alkalinization rate (JOHSL) were determined. Electrical stimulation of the preparations elicited increases in both JOHSL and Isc, which were inhibited by tetrodotoxin (TTX) and atropine. Physostigmine also evoked TTX- and atropine-sensitive increases in JOHSL and Isc. Similar increases in JOHSL and Isc were observed when the muscarinic agonist bethanechol chloride (BCh) was added to the serosal side. The responses to BCh were not affected by TTX. The BCh-induced increase in JOHSL was largely abolished by removal of HCO3- or Na+ and addition of ouabain (serosal side) but was neither sensitive to Cl- removal nor associated with 22Na secretion. The increase in Isc induced by BCh was associated with the increase in 36Cl secretion and was inhibited by removal of Cl- or Na+ and by addition of bumetanide or ouabain (both, serosal side). These results suggest that the submucosal cholinergic neurons are involved via muscarinic receptors in the stimulation of epithelial HCO3- and Cl- secretion. For both HCO3- and Cl-, the cellular and membrane mechanisms of secretion induced by muscarinic stimulation, although not entirely clear, appear to be different from those occurring under baseline conditions.

Effect of distal gastrectomy on gut hormone release following vagal stimulation in dogs

The effect of distal gastrectomy on gut hormone release was investigated by electrical stimulation of the posterior truncal vagus in dogs. Peripheral and portal plasma gastrin release was significantly inhibited, but peripheral and portal somatostatin release was unchanged. Peripheral and portal pancreatic polypeptide (PP) release was significantly inhibited. Our results suggest that the following factors might be some of the reasons why the secretion of PP was inhibited after distal gastrectomy: (1) transection of the posterior vagal branches close to the antrum and pylorus which might go to the pancreas; (2) changes in other hormones such as gastrin; (3) elimination of the PP secretagogue from the gastric antrum.

[Intentional hypotension therapy induced by nitroglycerin and the changes in the intracranial pressure for acute hemorrhagic intracranial lesions]

It is reported that nitroglycerin (NTG) induces the elevation of intracranial pressure (ICP). Because of it, the use of NTG in patients exhibiting the increased ICP especially in the neurosurgical field is thought to be avoided. However, these reported cases dealt with normal patients. Few cases under the condition of exactly increased intracranial pressure were studied. Our 31 patients of the hemorrhagic intracranial lesion (subarachnoid hemorrhage and hypertensive intracranial hemorrhage) at the acute stage were treated by NTG infusion as an antihypertensive drug, and the ICP was measured using the epidural pressure transducer. The 31 patients were divided into three groups. Group 1 consists of the 14 patients exhibiting normal ICP (< 15mmHg). Group 2 consists of 9 patients showing elevated ICP (15mmHg < or =). Group 3 consists of 8 patients treated with glycerol before the NTG infusion. Group 1 demonstrates a statistically significant elevation of ICP corresponding with the blood pressure depression. Group 2 showed no significant elevation of it. Group 3 disclosed no remarkable elevation of it both in the elevated ICP cases and the normal ICP cases. As mentioned above, the intravenous NTG caused a remarkable increase of ICP in the normal compliance of the intracranial contents and no elevation of ICP in the poor compliance. We conclude that NTG can be used for blood pressure control at an acute stage even in hemorrhagic intracranial lesion as anti-depressor.

[Effects of preoperative transcatheter portal embolization (TPE) on prevention of hepatic failure after massive hepatectomy]

Effects of TPE on prevention of hepatic failure after massive hepatectomy were studied experimentally using dogs. A 70% or 85% hepatectomy (Hx) was performed two weeks after TPE. All of the 70%Hx groups with(+)/without(-) TPE were alive for over two weeks after hepatectomy. While all of the 85%Hx group without TPE died, eight of ten in the 85%Hx group with TPE survived. Without TPE, total bilirubin levels in sera were elevated markedly in the 85%Hx group and moderately in the 70%Hx group after hepatectomy. The levels of escaped enzymes in sera, such as GOT or GPT, were also elevated remarkably in the TPE(-) groups. Although the levels of these enzymes were also high in the 85%Hx.TPE(+) group, these values were as same as those of 70%Hx.TPE(-) group. In the 85%Hx.TPE(-) group, critical diminution of functional hepatic cell mass and severe portal hypertension occurred after hepatectomy and coagulopathy and death followed to these phenomena. TPE might prevent the onset of these critical phenomena, and diminish the damage caused by massive hepatectomy. These results suggest that TPE is useful for prevention of postoperative hepatic failure so that we could perform massive hepatectomy safely, and extend the operative indication.

Effects of bile acids and bilirubin on bicarbonate secretion of isolated guinea pig antrum

The effects of bile acids and bilirubin, which increase in blood in obstructive jaundice, on bicarbonate secretion were studied experimentally using isolated antral mucosa of the guinea pig. Antral mucosal preparations were mounted between Ussing chambers. Basal and bethanechol-stimulated secretion were measured by a pH stat device using 5 mM HCl. After 10(-4), 10(-3), and 5 x 10(-3) M taurocholic acid, 10(-4) and 10(-3) M cholic acid, and 1.2 x 10(-4) and 2.4 x 10(-4) M bilirubin conjugate were added to the serosal solution, basal and bethanechol-stimulated secretion were also measured. Taurocholic acid, at any dose, did not affect basal secretion, but bethanechol-stimulated secretion was inhibited dose dependently. Cholic acid and bilirubin conjugate did not affect basal secretion, but bethanechol-stimulated secretion was significantly inhibited. Although the addition of bile acid or bilirubin into the serosal solution under experimental conditions is not the same as obstructive jaundice, these studies suggest that the inhibition of bicarbonate secretion in the gastric mucosa may have an important role in the formation of acute gastric mucosal lesions in obstructive jaundice.

Localization of blood coagulation factors in the germinal centers of human Peyer's patches

The immunohistochemical distribution of 15 blood coagulation factors in the germinal centers (GCs) of human Peyer's patches (PPs) was studied. Although factor VIII, active alpha-thrombin, and fibrinogen were hardly evident in the GCs, the majority of coagulation factors, such as kallikrein, high-molecular-weight kininogen, factors XII, X, IX, VII, V, XIIIa and XIIIb, prothrombin, anti-thrombin III and inactive alpha-thrombin were found, showing a lace-like staining pattern similar to that obtained with a monoclonal antibody, R4/23, specific for follicular dendritic cells (FDCs) in the GCs. By immunoelectron microscopy, positive reactions for factor X and XIIIa were found on the surfaces of FDCs, GC cells, and/or in the intercellular spaces of GCs, being especially marked on the surface of the labyrinth-like structure of FDCs. It is concluded that a majority of coagulation factors are localized in the GCs of human PPs. Furthermore, it is suggested that some of these coagulation factors have a close topographical relationship with FDCs.

[Surgical treatment of Marfan's syndrome with annulo aortic ectasia and mitral regurgitation]

This report is concerned with results of surgical treatment for Marfan's syndrome combined with annulo-aortic ectasia (AAE) and mitral regurgitation (MR). Of the 23 patients with Marfan's syndrome who received Bentall's procedure during 14 year period, seven (30%) of these patients had both AAE and MR. The MR grade of seven patients by cardiac Doppler or left ventriculographic studies were grade 1 in 2, 2 in 1, 3 in 1, and 4 in 3. Atrial fibrillation was present in 4 patients. New York Heart Association Functional Class on admission in these 7 patients were II in 1, III in 4, and IV in 2. The mitral valve was replaced with mechanical valve in 4 patients by left atrial approach whose MR grade were over 3. In the 4 patients the mitral annuli were extremely dilated, both valve leaflets were massively redundant, and all chordae were elongated and turned chordae and vegetation were detected due to infective endocarditis. Only Bentall's procedure was performed in 3 patients whose MR were minimal. There were no early death, but two late deaths. One of them died of cardiac failure 2.3 years after Bentall's procedure because grade 2 MR was increased. Another one died from ventricular arrhythmia 1.6 years after MVR and Bentall's procedure. The remaining 5 patients are doing well for 3 months to 11.5 years after operation. For Marfan's syndrome combined with AAE and MR, early operation is recommended before left ventricular impairment. Mitral valve repair was not performed, both to save time and because anticoagulant therapy was need for aortic valve replacement. Concomitant MVR was to be done for moderate to severe MR.

Effect of total-body cold exposure on plasma concentrations of von Willebrand factor, endothelin-1 and thrombomodulin in systemic lupus erythematosus patients with or without Raynaud's phenomenon

The effect of total-body cold exposure on plasma concentrations of von Willebrand factor (vWF), endothelin-1 (ET) and thrombomodulin (TM), all of which are considered to be generated from the endothelium, was studied in systemic lupus erythematosus (SLE) patients with and without Raynaud's phenomenon. The plasma levels of vWF, ET and TM in SLE patients, irrespective of the presence of Raynaud's phenomenon, were significantly higher than in normal controls even before the cold provocation test. After the cold provocation test, plasma levels of vWF and ET were significantly higher in SLE patients with Raynaud's phenomenon than in those without and in normal controls. No significant increase in TM was observed in either the SLE patients or the controls. These results suggest that SLE patients, regardless of the presence of Raynaud's phenomenon, are in a hypercoagulable state and that this state may be further intensified by cold exposure. Hence, it is concluded that we should consider antithrombotic therapy for SLE patients, especially those with Raynaud's phenomenon, to prevent unwanted activation of the coagulation system and possible endothelial damage.

Clinical significance of the venous occlusion test on systemic lupus erythematosus patients with a focus on changes in blood levels of tissue plasminogen activator, von Willebrand factor antigen, and thrombomodulin

We investigated the clinical significance of the venous occlusion (VO) test on patients with systemic lupus erythematosus (SLE) with or without circulating lupus anticoagulant (LA) concerning whether changes in the blood coagulation and fibrinolysis system in vivo subsequent to VO reflect mechanical stimulation of the endothelium or presence/development of endothelial damage. The tissue plasminogen activator antigen (tPA:Ag) before VO was much lower in the LA-positive patients than in the LA-negative ones (p < 0.01) and the von Willebrand factor antigen (VWF:Ag) pre-VO was significantly higher in the patient group, regardless of LA status, than in the control group (p < 0.01). But the mean increment in tPA:Ag and VWF:Ag post-VO, when expressed as the percentage of the baseline level, showed no appreciable difference between LA-positive and -negative groups. Thrombomodulin (TM) basically, on the other hand, was higher in the patients of either LA status than in the controls (p < 0.01) with a significant post-VO increase in the SLE group, which was more marked in the LA-positive patients, against no substantial change in the controls (p < 0.01). It is known that tPA and VWF:Ag are released simply as a result of endothelial stimulation and that the release of TM is preceded by endothelial damage. Based on the present results, we may well conclude that (1) the endothelium is functionally intact in SLE patients, (2) an injury of the endothelium, possibly as a consequence of vasculitis, preexists in LA-positive patients, and thus to measure the TM response to VO would offer a helpful tool in diagnosing the preexisting endothelial damage in these clinical settings.

[The hemodynamics during hemodilution and its influence on the liver functions after hepatectomy for hepatocellular carcinoma with liver cirrhosis]

The hemodynamics during hemodilution occurred after hepatectomy for hepatocellular carcinoma with liver cirrhosis and its influences on the liver functions were studied. The hematocrit value gradually decreased about 10% until the 4th postoperative day owing to hemodilution after hepatectomy. While anemia progressed, cardiac index inversely increased. Under such a condition, oxygen consumption was maintained so that acidosis did not develop. Arterial blood ketone body ratio was also kept within a normal range except for a case whose hematocrit value decreased to 17.1%. Although the escaped hepatic enzymes such as GOT and GPT increased in the serum after hepatectomy, hemodilution was not responsible for their increase. While total bilirubin increased in the severe hemodiluted group, the increase was not due to hemodilution but caused by blood transfusion. The protein synthesis of the liver measured by rapid turnover protein levels in plasma was depressed after surgery, and this depression prolonged to the 14th postoperative day in the group whose hematocrit value decreased below 20%. These results suggest that it is better to keep hemodynamics without blood transfusion unless the hematocrit value decrease below 20%, and also better to maintain the hematocrit above 20% for liver regeneration after hepatectomy.

[Reoperation of primary tissue failure of bioprosthesis in the mitral position]

The surgical results of 38 patients who underwent reoperation for primary tissue failure of bioprosthesis in the mitral position between May 1982 and June 1990 were analyzed to determine the risk factors affecting the hospital mortality. The type of bioprostheses requiring reoperation were Hancock valve in 21 patients, Liotta valve in 15 patients and Mitroflow valve in 2 patients. Twenty-five preoperative and perioperative variables were collected and analyzed by univariate statistics using chi 2 test or Student's test. Four of thirty eight patients died postoperatively in the hospital, yielding an overall mortality of 10.5%. The causes of hospital mortality were low output syndrome in 2 patients and multiple organ failure in 2 patients. By univariate analysis, male, NYHA IV class, prosthetic stenosis, hepatic failure, renal failure, and pulmonary failure were risk factors predictive of high hospital mortality. In spite of recent improvement of surgical technique and myocardial protection, the hospital mortality of patients with NYHA IV class and advanced organ failure still remains unacceptable. Therefore, it is essential to perform reoperation for primary tissue failure of bioprosthesis before severe myocardial decompensation occurs. To accomplish this goal, patients with bioprosthesis who survived beyond the certain time should be followed periodically using echocardiogram.

[Respiratory care with prone position for diffuse atelectasis in critically ill patients]

Diffuse atelectasis often occurs in the dorsal region of the lung of critically ill patients under long term mechanical ventilation. Conventional physical therapies (ex. PEEP, Sigh) have little effect on diffuse dorsal atelectasis. We provided respiratory care with prone position for 7 patients with severe respiratory distress (Two patients were treated twice). Improvement of their Respiratory Indexes (RI, mean 2.97) was obtained in the prone position for 6-163 (mean 35.8) hours. Ventilation efficiency also improved. Static lung compliance didn't change. It was assumed that the prone position was the factor responsible for the improvement of pulmonary V/Q ratio, the change of movement pattern of the diaphragm, and the ease of postural drainage of sputum. There were no complications. We conclude that prone position respiratory care has high utility for critically ill patients with diffuse dorsal atelectasis.

[Report of a case successfully weaned from long left ventricular assist with complete recovery after coronary artery bypass grafting]

A 45-year-old female underwent coronary artery bypass grafting (CABG) due to medically uncontrollable unstable angina. After completion of CABG, left ventricular contraction was remarkably diminished to maintain systemic circulation. Because intraaortic balloon pumping and veno-arterial bypass with large amount of catecholamines could not improve left ventricular wall function, we decided to use left ventricular assist device (LVAD). After application of LVAD, the patient could easily be weaned from cardio-pulmonary bypass. LVAD was used for 25 days and the patient was successfully weaned from LVAD too, and are now living 6 months postoperatively. As far as we know, this case is the first survival patient after the longest cardiac assist in our country.

[Long-term results of mitral valve replacement using glutaraldehyde-treated porcine bioprostheses--comparison of the Hancock and the Liotta valves]

Long-term results of mitral valve replacement using glutaraldehyde-treated porcine bioprostheses were evaluated. The subjects were 77 patients with the Hancock valve (Hancock group) and 60 with the Liotta valve (Liotta group) who survived operation. The maximum follow-up was 14 years and 8 years, and the cumulative follow-up was 631 patient-year (p-y) and 301 p-y in the Hancock and Liotta groups. The actuarial survival rate at 8 years was 80.1 +/- 4.6% for the Hancock group and 88.1 +/- 4.2% for the Liotta group, and there was no significant difference in survival rate between the both groups. The actuarial survival rate at 14 years was 74.3 +/- 5.9% for the Hancock group. The valve-related complications in the Hancock and the Liotta groups were as follow; thromboembolism 1.9%/p-y vs 1.3%/p-y, bleeding 0 vs 0.7%/p-y, perivalvular leak 0.3% vs 0, infection 0.3%/p-y vs 0.7%/p-y, primary tissue failure (PTF) 3.3%/p-y and all valve-related complications 5.9%/p-y vs 6.0%/p-y. There was no significant difference in valve-related complications between the both groups. However, the actuarial event free rate of PTF was significantly lower in the Liotta group than the Hancock group between 4 and 7 years after operation (100% vs 88.8 +/- 4.3% in the 4th year p less than 0.01, 87.7 +/- 4.4% vs 73.5 +/- 8.0% in the 7th year, p less than 0.05). Although the both anti-thrombogenicity and anti-inflammation were acceptable in the porcine bioprostheses, this prosthesis is now used only in the selected patients because of the limited long term durability of this valve.

[Distribution pattern of Dirofilaria immitis microfilariae in peripheral blood of a dog and their intake by mosquitoes]

Experiments were made in which Aedes aegypti mosquitoes fed on a dog infected with Dirofilaria immitis, in order to determine the distribution pattern of microfilariae (Mf) in the dog's periphery blood and the number of Mf taken by the mosquitoes. Mosquitoes fed on an anesthetized dog at some 50 shaved skin spots and they were weighed immediately before and after feeding. This enabled us to examine not only the Mf number taken by each mosquito but also the Mf intake density in terms of Mf number per mg of blood. The Mf intake density showed a wide variation at the different parts of the dog's body, and the frequencies of Mf showed uneven distributions which were fitted best by the negative binomial. Significant differences were detected in the Mf intake density at different parts of the skin, but these differences were concluded as a non-consistent result because a similar result was not reproduced in the next experiment. It was presumed that not only the Mf number per mosquito but also the Mf intake density increased as the blood intake by the mosquitoes increased. This increase of both the Mf number per mosquito and the Mf intake density was also supported by another experiment in which mosquitoes were fed at the same skin spots consecutively one after another.

[Plasma and tumor gastrin in patients with primary hyperparathyroidism]

It is well known that primary hyperparathyroidism is often associated with peptic ulcer. The purpose of this study is to confirm the relationship between the gastrin-levels before and after parathyroidectomy in fourteen patients with primary hyperparathyroidism, and to determine the localization of gastrin in the surgically resected parathyroid tumor. The results obtained were as follows: 1) Three patients had peptic ulcer (gastric ulcer and duodenal ulcer), the incidence being 21%. 2) The basal serum gastrin levels were 123.0% +/- 68.1 pg/ml before operation and decreased to 90.2 +/- 44.5 pg/ml after operation. In the 3 patients with slightly elevated gastrin levels, the mean level before operation was 209.1 +/- 61.2 pg/ml. The gastrin level decreased to 116.4 +/- 62.0 pg/ml after operation. 3) Gastrin immunoreactivity was detected in 10 out of 14 tumors and its localization was at the periphery of tumor cells. From these results, we conclude that extragastric gastrin secretion from parathyroid tumors may be one of the cause of peptic ulcer in patients with primary hyperparathyroidism.

Angiotensin-converting enzyme inhibitors: synthesis and biological activity of N-substituted tripeptide inhibitors

A new series of highly potent angiotensin-converting enzyme (ACE) inhibitors, 1-(N2-substituted L-lysyl-gamma-D-glutamyl)octahydro-1H-indole-2-carboxylic acids, was synthesized; various acyl groups were introduced at the alpha-amino group of the N-terminal P1 Lys. The effect of the N2-acyl groups on in vitro inhibitory activity and oral antihypertensive effect was examined. All of the synthesized N-acyl tripeptides were found to have in vitro inhibitory activity at an approximately nanomolar level, and showed antihypertensive potency in renal hypertensive rats at a dose of 10 mg/kg, when administered orally. Among them, compounds 7e, g and 9f, i, m showed potent and long-lasting antihypertensive effects compared with enalapril (2a). Their structure-activity relationships are also discussed.

[Evaluation of color pattern VECP in deutan]

Using an Equi-Energy-Color Pattern Generator, color vision experiments were performed on nine normal subjects, six cases of deuteranomalies, and six cases of deuteranopias with the use of Visually-evoked cortical potentials (VECPs). Checkerboard patterns, consisting of the pairing of any chosen one of three colors with its complementary color in terms of equal energy, were used. The pairing of a neutral color with its complementary color of protan, deutan and tritan were displayed on a color TV monitor. We measured the amplitude and latency of P100 component of VECPs. Cases of deuteranopia showed significantly smaller amplitude and longer latency of P100 component in protan and deutan responses than did normal subjects. Cases of deuteramomaly showed significantly smaller amplitude and longer latency of P100 component in only protan response compared to those of normal subjects. It was possible to objectively detect the deutan in color pattern VECPs.

[The treatment of accompanied organ failure after thoracic and cardiovascular surgery with mechanical organ-supports]

Five hundred and thirty-three patients have been treated after thoracic and cardiovascular surgery in our ICU during the last four years. Cardiac failure was shown in 150 cases, respiratory failure in 132 cases, renal failure in 76 cases, and hepatic failure in 84 cases. The appropriate mechanical organ-supports (MOS) were applied in the following cases: intra-aortic balloon pumping (IABP) in 48 cases, veno-arterial bypass (VAB) in 18 cases, left ventricular assist device (LVAD) in 1 case, respirator in 132 cases, continuous hemofiltration (CHF) in 44 cases, hemodialysis (HD) in 13 cases, peritoneal dialysis (PD) in 21 cases, Continuous intensive peritoneal dialysis (CIPD) in 7 cases, and plasma exchange (PEx) in 22 cases. The results of MOS6 which required exocorporeal circulation were not satisfactory, especially CHF (mortality rate 75.0%), HD (76.9%), and VAB (100%). Though, the results of IABP (35.4%) and CIPD (14.3%) were significantly better. The main cause of early death (within 6 post-operative days) was low output syndrome (LOS) (63.6%). However, that of late death (beyond 14 post-operative days) was sepsis (66.7%). Therefore, it is important for the survival of these patients to control LOS during the early post operative period and then to concentrate on the prevention of infection.

Angiotensin-converting enzyme inhibitors: synthesis and structure-activity relationships of potent N-benzyloxycarbonyl tripeptide inhibitors

A new series of gamma-D-Glu-containing N-benzyloxycarbonyl (Z) tripeptide inhibitors of angiotensin-converting enzyme (ACE) was synthesized. The effect of varying the antepenultimate amino acid residue in this series on the biological activity was studied. Introduction of Lys and Orn residues at the P1 position provided the most potent inhibitors, 25a and 25b (IC50: 3.5 and 4.9 x 10(-9) M, respectively), which exhibited an oral antihypertensive activity. This result suggests that basic amino acid residues at the P1 position play an important role in binding with the S1 subsite of ACE in this series. Oral antihypertensive activity of selected compounds was evaluated.

[A case report of emergency thoracotomy and aortic cross clamp for massive abdominal hemorrhage due to the rupture of a pancreatic pseudocyst]

The authors present a rare case of a 58-year-old female who had cardiac arrest due to massive abdominal hemorrhage because of the rupture of pancreatic pseudocyst during an emergency operation. We succeeded in resuscitation by performing emergency thoracotomy and internal cardiac compression. Thoracic aortic cross clamping was employed to control bleeding, and we could perform the operation. She recovered without any neurological deficits. Thoracic descending aortic cross clamping should be always considered both before and during operation for the control of massive abdominal hemorrhage to avoid circulatory collapse.

[Surgical management of acquired tricuspid valve disease--the effects and comparison of tricuspid annuloplasty (De Vega) and tricuspid valve replacement]

A total of 92 patients with tricuspid valvular disease (TR) had surgical repair of DeVega's annuloplasty in 80 patients (87%) and of valve replacement in 12 patients (13%) from January, 1978, to March, 1988. All of those patients were diagnosed by cardiac catheterization and angiogram, clinical findings and in recent cases, pulsed and color Doppler echocardiography were applied. Eighty-nine of 92 patients (97%) were in NYHA class III or IV before operation. There were 7 early death (8.5%) with DeVega procedure and one death (8.3%) in TVR and late deaths were noted in 3 patients (3.6%) (DeVega's procedure) and one (8.3%) in TVR. Two patients after DeVega procedure at 5 and 6 years were required re-operation of TVR because of recurrent mitral valvular disease. Seventy-seven of 80 survivors were in NYHA class I or II postoperatively. Twenty-seven randomized selected patients after DeVega's annuloplasty were investigated by pulsed and color Doppler echocardiography, 17 of them (63%) had no regurgitation and the remaining 10 patient had mild to moderate regurgitation. This study suggests that DeVega's annuloplasty has a simple and reliable procedure in patients with functional TR and results in excellent hemodynamic and functional effects postoperatively.

The thrombolytic effects of native tissue-type plasminogen activator (AK-124) on experimental canine coronary thrombosis

To evaluate the thrombolytic effects of the native tissue-type plasminogen activator (t-PA), the authors used a thrombus model simulating clinical situations. The native t-PA (AK-124) was obtained from human-derived normal cells. Experimental canine coronary thrombosis was produced by partial constriction and endothelial denudation of the vessel. In 19 dogs, coronary occlusive thrombus was produced. Three hours after total occlusion of the coronary artery with thrombus, the authors attempted the thrombolytic therapy in 16 dogs. Histologically, three-hour thrombus was composed of a mixture of platelet aggregates, fibrin, and blood cells. They infused 0.375 mg/kg t-PA intravenously in 7 dogs and 20,000 IU/kg urokinase (UK) in 9. Coronary recanalization was achieved in 5 (71%) with t-PA infusion and 6 (67%) with UK infusion. Plasma fibrinogen levels decreased to 76% of preinfusion value in the dogs with t-PA infusion and to 34% in those with UK infusion. Coronary reocclusion occurred in 2 dogs with t-PA and 3 with UK. Thus, the native t-PA (AK-124) can provide coronary thrombolysis without severe depletion of plasma fibrinogen levels.

Enhancement of arterial thrombolysis with native tissue type plasminogen activator by pretreatment with heparin or batroxobin: an angioscopic study

The enhancement of canine arterial thrombolysis with native tissue type plasminogen activator (nt-PA) obtained from human-derived normal cells by pretreatment with heparin or the defibrinogenating agent, batroxobin, was evaluated with angioscopy. The nt-PA, 0.25 mg/kg, was infused intravenously to lyse 1-hour-old thrombus (eight thrombosed arteries without medication, seven with nt-PA alone, seven with nt-PA and heparin, and seven with nt-PA plus batroxobin). Angioscopy provided a cross-sectional view of the vessel lumen with clear visualization of the thrombus. Thirty minutes after nt-PA infusion, the percent luminal obstruction decreased from 74 to 61 in nt-PA alone (p less than .025), from 77 to 37 in nt-PA plus heparin (p less than .005), and from 79 to 25 in nt-PA plus batroxobin (p less than .005). Fifteen minutes after drug infusion, plasma fibrinogen levels decreased to 89% of preinfusion value in nt-PA alone, to 84% in nt-PA plus heparin, and to less than 5% in nt-PA plus batroxobin. Thus rapid infusion of nt-PA alone provided slight thrombolytic effects. However, heparin and batroxobin showed marked enhancement of thrombolytic effects of nt-PA.

[An immunohistochemical study of endogenous estradiol and testosterone in human colo-rectal cancer tissues]

An immunohistochemical method (peroxidase antiperoxidase method) was carried out to examine the distribution of endogenous estradiol (E2) and testosterone (Te). One hundred and twenty four (48.2%) of 257 colo-rectal cancer cases, and 36.7% of male cases and 58.4% of female cases revealed E2-immunostain. This immunohistochemical reaction for E2 was found more frequently in female patients than in male patients, while Te-immunostain was found in 15 (17.6%) of 85 colo-rectal cancer cases. E2 and Te were demonstrated mainly in the cytoplasms and occasionally in the nuclei of cancer cells. Since E2 or Te-positive cancer cells were mainly distributed in the deeper or invasive portion of tissue sections, it might deserve further investigation to elucidate a certain relationship between cancer growth and endogenous sex-hormones.

Pathogenesis of water-immersion stress-induced gastric ulcers in rats with renal failure

Rats with or without renal failure, produced by uranyl acetate, were subjected to water-immersion stress for 6 h. The severity of stress-induced gastric ulcers in the renal failure group was significantly higher than that in the control group. The intragastric pH did not significantly differ between the two groups. Transmucosal electrical potential difference, gastric mucosal blood flow, and gastric mucosal hexosamine content in the renal failure group were significantly lower than in the control group. These results suggest that decreases in defensive factors, rather than an increase in an aggressive factor, may be more closely involved in the development of acute gastric ulcers in rats with renal failure.

Experimental studies on the pharmacokinetics and therapeutic effect of cefbuperazone in biliary infection

A study was carried out using an experimental biliary infection model to investigate the pharmacokinetic characteristics and therapeutic effect of cefbuperazone in the rabbit. Thirty rabbits were divided into three equal groups; a control group of normal animals, a group of infected animals receiving no cefbuperazone, and a group of infected animals receiving 50 mg cefbuperazone/kg intramuscularly. The experimental infection was made by direct inoculation of a suspension of E. coli into the common bile duct after ligation. The results showed that extremely high levels of cefbuperazone were achieved in bile and tissues of the biliary tract and were higher than those in the blood. Moreover, the levels were maintained at effective concentrations even after 6 hours. Viable bacterial cells from bile and the gall-bladder were barely detectable 24 and 48 hours after infection in the cefbuperazone-treated group, whilst counts remained high in the other infected group. White blood cell counts were increased at 24 hours after infection but were significantly lower in the cefbuperazone-treated group. Histological examination revealed marked inflammatory changes in the gall-bladder and bile duct of infected, untreated animals but few, mild changes only were seen in cefbuperazone-treated animals. Similarly, total bilirubin and liver enzymes were markedly increased in infected animals, but transaminases and alkaline phosphatase were significantly lower in the treated compared to the untreated group. The findings indicate, therefore, that cefbuperazone can be a useful antibiotic in biliary infection.

[Diagnosing the depth of esophageal carcinoma invasion by esophagography scoring]

In patients with an esophageal carcinoma, it was important to determine the depth of the carcinomatous involvement so as to decide on its resectability and prognosis. Thus four measurements of the esophagography findings involving ninety five post-esophagectomy patients were categorized into four grades and scored from point 1 to point 4, depending on the degree of severity, the measurements being the size of the tumor, the circumferential carcinomatous invasion, the degree of stenosis, and the depth of the ulcer. The sum total scores of these four esophagography findings were found to correlate well (P less than 0.01) with the depth of the invasion (submucosa, muscularis propria, adventitia, and the adjacent structures).

Isolation and identification of prostaglandin I 2 stimulating factor from human plasma

To isolate and identify the plasma factor which stimulates prostaglandin I 2 production by rat aortic ring, a human plasma fraction which showed a major stimulating activity on prostaglandin I 2 production was purified by ultrafiltrate, Sephadex G-10 gel filtration and QAE-Sephadex column chromatography. The purified plasma factor was identified as uric acid by its ultraviolet and infrared absorption spectroscopy, and 1H nmr and 13C nmr spectroscopy. The stimulating activity of the purified plasma factor and that of authentic uric acid coincided with each other. The stimulating potency of uric acid at its physiological concentration in human plasma (about 50 micrograms/ml) was half of the deproteinized human plasma, and was about 30 fold stronger than that of L-tryptophan, a cofactor of prostaglandin hydroperoxidase.

[Cooperative research on post-operative adjuvant therapy of breast cancer. Tohoku Society of Adjuvant Chemo-endocrine Therapy of Breast Cancer]

A randomized trial was carried out in 55 institutes in the Tohoku district to examine the significance of breast cancer post-operative adjuvant chemo-endocrine therapy in stage II and IIIa patients for possible radical mastectomy. A total of 619 patients were entered from November 1982 to November 1984, of whom 554 were eligible. Patients were administered MMC 13 mg/m2 after surgery, and randomized using the envelope method into either group A, treated with Tegafur 400 mg/m2 alone (275 patients), or group B, treated with Tegafur 400 mg/m2 and Tamoxifen 20 mg/daily (279 patients), for a year from the 7th day after operation. There was no significant difference between the two groups in the background factors of age, menopausal status, operation methods, stage or number of positive lymph nodes, but there were more patients of ER(+) in group B. A Kaplan-Meier method comparison showed no significant difference between the two groups in 3-year disease-free survival rates. There was no significant difference between the two groups compared by ER or menopausal status. However, patients with 4 or more positive lymph nodes showed a significant benefit in group B. Group B also marked a higher disease-free survival rate for ER(+) patients with 4 or more positive lymph nodes.

[Pulmonary dirofilariasis found unexpectedly during thymectomy]

A 56-year-old woman in Kitakyushu City was operated on after diagnosis of mediastinal tumor with myasthenia gravis. Besides the thymoma, a small nodule was palpated in the lower lobe of the left lung and biopsied. A segmented worm was found in sections of this granulomatous nodule. A cross section of the degenerated worm (400 X 310 micron) showed a 3-layered tegument and internal cuticular ridges with high lateral chords. The muscle layer consisted of high and polymyarian muscles. Based on these characteristics, this worm was identified as an immature dog heartworm, Dirofilaria immitis. The recent sharp increase of dirofilariasis cases reported in Japan is discussed.

[A case of small cell carcinoma of the esophagus]

The case of a 51-year-old man, complaining of a sense of pressure on his chest, is reported. Tests led to a diagnosis of a cancer in the midesophagus and a subtotal esophagectomy was performed. The tumor was found to be a protruded type, 8.5 X 7.0 cm in size. A histologic diagnosis revealed it to be a small cell anaplastic carcinoma. The tumor cells were found negative in a Grimelius staining and did not contain hormones such as ACTH. Some cytokeratins, however, were detected by an immunohistochemical examination, Cancer invasion into the adventitia was seen, though no lymph node metastasis or a distant metastasis was shown. Six months after operation, a recurrence in the mediastinum and in the distant lymph nodes was found. Chemotherapy and irradiation were found to be useful, and the postoperative survival period was 25 months.

[A case report of nasal infestation by the leech, Dinobdella ferox]

A 55-year-old man in Okagaki Town, Fukuoka Prefecture, pulled a nasal leech from his nostril in July 1987, after suffering from nosebleed, copious running snivels as well as unpleasant foreign body sensation in the nasal cavity. Except for nasal septum deviation, no abnormality in the ears and mouth cavity nor bleeding, ulcerous and erosive changes in the nasal cavity were found. The formalin-fixed specimen of the leech was nearly black with no definite stripes or spots, and measured 3.5 cm in length and 1.2 cm in width. Because of these and the following characteristics, viz. 1) auricles on the posterior segment were absent, 2) five pairs of eyes were present in the anterior segments with the eye pairs 3 and 4 separated by an annulus, and 3) teeth were not observed, this specimen was identified as Dinobdella ferox. This nasal leech is found widely in Southeast Asia. In Japan, some human cases of its infestation have also been reported, mainly from southern Kyushu. The leech seemed to have entered the nasal passage of the present case from a stream at a hot spring in northern Kyushu. Attention should be given to nasal leech infestation especially now that many people in Japan are eager to visit isolated hot spring resorts.

[Three recent cases of ascariasis in northern Kyushu]

Ascariasis is considered to be one of the rare infectious diseases in Japan, but recently it has been slightly increasing. This paper reports three ascariasis cases who seemed to be infected recently in the Kitakyushu area, Japan. Case 1: A 59-year-old woman in Kitakyushu City passed a round worm after continuous abdominal pain. The patient was discharged from the hospital because of no further abnormal intestinal symptoms and findings. Case 2: An 85-year-old woman in Nakama City, who suffered from cerebral infarction, vomited a round worm before hospitalization. Many ascarid eggs were detected after admission, and after treatment with pyrantel pamoate (Combantrin) two round worms were passed and egg detection became negative. Case 3: A 77-year-old man in Saikawa Town vomited 3 round worms after gastrectomy due to early gastric cancer. Many unfertilized eggs were also detected from the stool together with hook worm eggs, but no eggs were found after administration of pyrantel pamoate. Morphological examination was made by a scanning electron microscope on the denticles on the dentigerous lip ridges of the worms to differentiate from possible infection with a pig parasite, Ascaris suum. The three cases were diagnosed as ascariasis due to human Ascaris lumbricoides based on the following evidences that the expelled worms had 1) less pointed tips of the denticles and shallower or wider interdenticle notches, and 2) far more denticles of smaller size along the dentigerous ridges, compared with Ascaris suum. The necessity of differentiating pig- from human-ascarids, when considering human infection with Ascaris suum, is discussed.