Bronchovascular cuff formation and lung lymph flow in edema formation of anesthetized sheep

The relationship between bronchovascular cuff formation and lung lymph flow in hydrostatic edema was evaluated. After a balloon was inserted into the left atrium to increase left atrial pressure for 5 hrs, peripheral lung tissues were resected for analysis of the wet-dry ratio and cuff formation. The degree of cuff formation was expressed as the cuff ratio (outer diameter of cuff/outer diameter of microvessel or airway) in three size categories: 80-200, 200-400, and 400-750 microm in diameter. The amount of excess lung lymph (Ex LL) for 5 hrs was calculated from the recorded data for the whole lymph flow wave. The wet-dry ratio showed a significant correlation with ALAP and lung lymph flow increased significantly (flow rate, 0.67 +/- 0.46 ml/min (mean +/- SD); Ex LL, 56.4 +/- 47.6 ml). Cuff formation was found at all levels of the bronchovascular tree, with a larger cuff ratio (> 1.3) observed at arteries and veins of 80-200 microm in diameter, but a significant correlation with Ex LL was found only for arteries of 80-200 microm. Fluid accumulation in lung interstitium first occurred at smaller extra-alveolar arteries even under mild hydrostatic pressure elevation with a significant increase in lymph flow.

Vasopressin-dependent upregulation of aquaporin-2 gene expression in aged rats with glucocorticoid deficiency

AIM

The study was undertaken to determine whether ageing affects kidney expression of the aquaporin-2 (AQP2) water channel in glucocorticoid-deficient rats.

METHODS

After adrenalectomy, 6- and 52-week-old Sprague-Dawley rats received aldosterone via osmotic minipumps (glucocorticoid-deficient rats). Aldosterone and dexamethasone were administered to control rats of the same age.

RESULTS

An acute water load test verified impairment of water excretion in both young and aged rats with glucocorticoid deficiency, with a more serious impairment in the older rats. Despite the presence of hypoosmolality, non-suppressible release of arginine vasopressin (AVP) was particularly evident in the aged rats with glucocorticoid deficiency in comparison with the young rats. The expression levels of AQP2 mRNA and protein were lower in the aged rats, with a particularly large reduction in AQP2 protein expression. AQP2 expression levels were significantly augmented in the glucocorticoid-deficient rats compared with the controls under both basal and water-loaded conditions. Acute water loading did not suppress expression of AQP2 mRNA and protein, and the percentage increases in AQP2 mRNA and protein expression vs. the respective controls were more pronounced in the 52-week-old glucocorticoid-deficient rats compared with the 6-week-old rats.

CONCLUSION

The findings indicate that upregulation of AQP2 expression is maintained dependent upon non-suppressible release of AVP in rats with glucocorticoid deficiency, and that AQP2 plays a crucial role in persistent impairment of water excretion in aged rats with glucocorticoid deficiency.

[Combined surgery for ischemic cardiomyopathy]

The results of combined surgery for ischemic cardiomyopathy were reviewed focusing on the selection of operative procedures. Left ventricular volume reduction was performed in 33 patients. Hospital mortality was 17% in Dor procedure (n=24), 20% in Batista operation (n=5) and 0% in over-lapping method (n=4). Procedures should be selected according to left ventricular wall area to be excluded. Mitral valve plasty was performed in 50 patients, and early and late results of our original "papillary muscle sandwich plasty" (n=27) was superior to those of other conventional procedures (n=23). In "sandwich plasty", the papillary muscle heads of the anterior and the posterior mitral valve leaflets are approximated using tefron-pledgeted 3-0 ticron suture at the anterolateral and posteromedian commissural portions, respectively. In conclusion, active combined surgery is necessary for the treatment of ischemic cardiomyopathy.

Surgery for infective endocarditis: determinate factors in the outcome

AIM

The appropriate operative procedures for treatment of infective endocarditis (IE) are still controversial. The authors reviewed their own operative results focusing on preoperative risk factors, intraoperative findings and operative procedures.

METHODS

The authors reviewed the cases of 40 adult patients who had undergone surgery since 1999. The mean age of patients was 58 years ranging from 31 to 78 including 30 males and 10 females. Thirty-three patients had native valve endocarditis (NVE) and the remaining seven patients had prosthetic valve endocarditis (PVE). Diseased lesions were located in the mitral valve (MV) in 21 patients, aortic valve in 15 and mitral plus aortic valves in four. Twenty-eight patients (70%) were operated on during the active phase of IE. Streptococcus, Staphylococcus and Enterococcus species were predominant in the bacterial examination.

RESULTS

Active vegetation was observed in 26 (65%) patients. Perforation of valve leaflets was observed in 11 (28%) cases. Changes of native MV leaflet were mild in 8 (40%) out of 20, which seemed to be reparable, while, changes of the native aortic valve leaflet were moderate to severe in 13 (87%) out of 15 patients. Valvular annuls were involved in the infection in 17 (43%) patients. Of the 33 NVE patients, prosthetic valve replacement was performed in 29 patients including 19 mitral and 15 aortic valves. MV plasty was performed in 4 patients. In seven PVE patients, prosthetic MV replacement was performed twice. In the aortic group, three patients underwent aortic root translocation, The Ross procedure and standard root replacement were performed respectively. Four patients died after surgery including one NVE case and three PVE cases. Three PVE patients who underwent aortic root translocation or the Ross procedure survived. The hospital mortality of NVE and PVE surgery was 3% and 43% (P<0.01), respectively. By univariant analysis, there were no significant correlations between operative results and preoperative factors such as bacteria, infective phase, cardiac failure, renal failure, sepsis or brain morbidity. The only significant factor on hospital mortality was PVE. Three patients died of non-cardiac diseases during the follow-up period.

CONCLUSION

Operative results of NVE were good after complete resection of infective sites including valve annulus. Both valve replacement and plasty were available for NVE patients. In PVE, new strategies are indispensable and aortic root translocation or the Ross procedure should be a treatment of choice.

Abnormal expression of the genes involved in cytokine networks and mitochondrial function in systemic juvenile idiopathic arthritis identified by DNA microarray analysis

Objectives:

Systemic juvenile idiopathic arthritis (sJIA) is a rheumatic disease in childhood characterised by systemic symptoms and a relatively poor prognosis. Peripheral leukocytes are thought to play a pathological role in sJIA although the exact cause of the disease is still obscure. In this study, we aimed to clarify cellular functional abnormalities in sJIA.

Methods:

We analysed the gene expression profile in peripheral leukocytes from 51 patients with sJIA, 6 patients with polyarticular type JIA (polyJIA) and 8 healthy children utilising DNA microarrays. Gene ontology analysis and network analysis were performed on the genes differentially expressed in sJIA to clarify the cellular functional abnormalities.

Result:

A total of 3491 genes were differentially expressed in patients with sJIA compared to healthy individuals. They were functionally categorised mainly into a defence response group and a metabolism group according to gene ontology, suggesting the possible abnormalities in these functions. In the defence response group, molecules predominantly constituting interferon (IFN)γ and tumour necrosis factor (TNF) network cascades were upregulated. In the metabolism group, oxidative phosphorylation-related genes were downregulated, suggesting a mitochondrial disorder. Expression of mitochondrial DNA-encoded genes including cytochrome c oxidase subunit 1(MT-CO1) and MT-CO2 were suppressed in patients with sJIA but not in patients with polyJIA or healthy children. However, nuclear DNA-encoded cytochrome c oxidases were intact.

Conclusion:

Our findings suggest that sJIA is not only an immunological disease but also a metabolic disease involving mitochondria disorder.

Ambulatory blood pressure is a better marker than clinic blood pressure in predicting cardiovascular events in patients with/without type 2 diabetes

BACKGROUND

The prognostic significance of ambulatory blood pressure (ABP) has not been established in patients with type 2 diabetes (T2DM).

METHODS

In order to clarify the impact of ABP on cardiovascular prognosis in patients with or without T2DM, we performed ABP monitoring (ABPM) in 1,268 subjects recruited from nine sites in Japan, who were being evaluated for hypertension. The mean age of the patients was 70.4 +/- 9.9 years, and 301 of them had diabetes. The patients were followed up for 50 +/- 23 months. We investigated the relation between incidence of cardiovascular diseases (CVDs) and different measures of ABP, including three categories of awake systolic blood pressure (SBP <135, 135-150, and >150 mm Hg), sleep SBP (<120, 120-135, and >135 mm Hg), and dipping trends in nocturnal blood pressure (BP) (dippers, nondippers, and risers). Cox regression models were used in order to control for classic risk factors.

RESULTS

Higher awake and sleep SBPs predicted higher incidence of CVD in patients with and without diabetes. In multivariable analyses, elevated SBPs while awake and asleep predicted increased risk of CVD more accurately than clinic BP did, in both groups of patients. The relationships between ABP level and CVD were similar in both groups. In Kaplan-Meier analyses, the incidence of CVD in nondippers was similar to that in dippers, but risers experienced the highest risk of CVD in both groups (P < 0.01). The riser pattern was associated with a approximately 150% increase in risk of CVD, in both groups.

CONCLUSIONS

These findings suggest that ABPM is a better predictor of cardiovascular risk than clinic BP, and that this holds true for patients with or without T2DM.

[Tracheoplasty for tracheal cuff stenosis post long-term tracheostomy]

We encountered a case of tracheal stenosis post tracheostomy, so-called cuff stenosis. A 43-year-old man with ventricular septal defect (VSD) was treated by oral endotracheal intubation because of heart-failure and pneumonia, and tracheostomy was performed. He was placed on artificial ventilation for almost 3 months. Four months after discharge, he complained of dyspnea and was treated by oral endotracheal intubation again. At that time bronchofiberscopy demonstrated severe circumferential stenosis of the trachea 4 cm from the tracheostomy spot and that was compatible with the cuff site. Although the stenotic portion was dilated by an endotracheal tube, 47-days after dilation, the portion was restenosed to almost 7 mm in diameter. Therefore, surgical treatment was necessary and tracheoplasty was performed by end-to-end suture after 2 cm (4 ring) resection of trachea. Tracheoplasty is the most reliable method of treating cuff stenosis after tracheostomy.

What factors influence the results of coronary artery bypass grafting in aged patients?

AIM

Early and late results were studied in order to improve the indication for coronary artery bypass grafting (CABG) and to enhance

RESULTS

METHODS

A total of 1 973 patients aged 70 years and older who had undergone isolated CABG were studied. Elective operations (EL) were performed in 1 716 patients and 257 patients underwent urgent or emergency operations (UR/EM). Patients were divided into two groups; 104 patients aged 80 years and older (Oct. Group) and 1 869 patients of septuagenarians (Sept. Group). There were no differences between the groups in the number of diseased vessels.

RESULTS

Total operative mortality rates in the Oct. and the Sept. groups were 7% and 4%, respectively. The operative mortality of elective surgery was 4% in both groups. The operative mortality of UR/EM CABG was significantly higher in the Oct. group than in the Sept. group (21% vs 6%). Operative mortality was significantly higher in patients with preoperative poor (<49%) left ventricular ejection fraction (LVEF) than in patients with higher (>50%) LVEF (6% vs 3%). Among preoperative risk factors, diabetes mellitus and peripheral vascular disease were significant contributory factors to operative death. In the follow-up study, 70% patients of the Oct. group and 72% patients of the Sept. group survived. Preoperative number of diseased vessels and number of CABG grafts did not influence the early and late

RESULTS

CONCLUSION

Preoperative poor LVEF, diabetes mellitus and peripheral vascular disease were significant contributory factors to operative death. When feasible, CABG in octogenarians should be performed electively.

Japanese collaborative study to assess inter-laboratory variation in factor VII activity assays

BACKGROUND

The clinical phenotype manifest by patients with factor VII (FVII) deficiency correlates poorly with that predicted by laboratory tests. Despite its importance, there are no data on the variability of inter-laboratory determinations of low to very low plasma FVII activity (FVII:C).

METHODS

We distributed three FVII-deficient plasma samples, prepared by immunoaffinity chromatography, to 58 laboratories in Japan. All samples were assayed using standardized reference plasma as a calibrator. Recombinant thromboplastin was also supplied as a common reagent.

RESULTS

In the case of sample A, which had a very low FVII:C, the use of standardized reference plasma and thromboplastin, lowered the variability of inter-laboratory measurements, when compared with the variability observed when samples were assayed using the respective laboratory's routine method.

CONCLUSIONS

The data obtained indicated that results for samples with a very low FVII:C were greatly influenced by the number of plasma dilutions used in constructing a standard activity curve, and also by the type of calibrator and thromboplastin. Such variability was not seen for samples with moderate FVII:C. We conclude that it is necessary to develop a more sensitive and accurate FVII:C measurement system for the diagnosis and treatment of FVII deficiency.

Identification of the transforming EML4-ALK fusion gene in non-small-cell lung cancer

Improvement in the clinical outcome of lung cancer is likely to be achieved by identification of the molecular events that underlie its pathogenesis. Here we show that a small inversion within chromosome 2p results in the formation of a fusion gene comprising portions of the echinoderm microtubule-associated protein-like 4 (EML4) gene and the anaplastic lymphoma kinase (ALK) gene in non-small-cell lung cancer (NSCLC) cells. Mouse 3T3 fibroblasts forced to express this human fusion tyrosine kinase generated transformed foci in culture and subcutaneous tumours in nude mice. The EML4-ALK fusion transcript was detected in 6.7% (5 out of 75) of NSCLC patients examined; these individuals were distinct from those harbouring mutations in the epidermal growth factor receptor gene. Our data demonstrate that a subset of NSCLC patients may express a transforming fusion kinase that is a promising candidate for a therapeutic target as well as for a diagnostic molecular marker in NSCLC.