Changes in T-cell receptor subsets after cardiac surgery in children

T cells are divided into two subsets, alphabeta and gammadelta, according to the T-cell receptor (TCR) expressed. Recent findings indicate that gammadelta T cells serve as the first defense against microbial pathogens, and represent a link between innate and acquired immunity. We conducted a study to investigate the changes in circulating TCR subsets after cardiac surgery in children. Blood samples from 24 children who underwent cardiac surgery with cardiopulmonary bypass (CPB) were collected serially to analyze TCR subsets by flow cytometry. The alphabeta T cells reached a nadir on postoperative day (POD) 1, but recovered to pre-CPB levels on POD 3. On the other hand, the gammadelta T cells decreased after CPB and did not recover to pre-CPB levels even after POD 7. The alphabeta/gammadelta T-cell ratio was increased after POD 3. In children, gammadelta T cells recover more slowly than alphabeta T cells after cardiac surgery. These changes in TCR subsets may contribute to postoperative immunosuppression.

Magnetic resonance imaging for early detection of Takayasu arteritis

The patient was a 15-year-old girl with suspected Takayasu arteritis. Magnetic resonance (MR) imaging, using the fast low angle shot (FLASH) technique, revealed aneurysmal dilation of the aortic root and irregular thickening of the aortic wall. Three-dimensional (3-D) contrast-enhanced MR angiography successfully demonstrated narrowing of the left carotid and left subclavian arteries. In addition, 2-dimensional (2-D) FLASH MR imaging clearly visualized narrowing of two right renal arteries and the left renal artery. These were angiographically evident. Thus, MR imaging is particularly useful for early detection of subtle arteritic changes and involvement of stenotic lesions in branch vessels in the early phase of Takayasu arteritis.

Novel non-peptide GPIIb/IIIa antagonists: synthesis and biological activities of 2-[4-[2-(4-amidinobenzoylamino)-2-(substituted)acetyl]-3-(2-methoxy-2-oxoethyl)-2-oxopiperazinyl] acetic acids

To improve the in vitro and in vivo potency of our first low molecular weight GPIIb/IIIa antagonist 1 (TAK-029), a series of 2-[4-[2-(4-amidinobenzoylamino)-2-(substituted)acetyl]-3-(2-methoxy-2-oxoethyl)-2-oxopiper-azinyllacetic acids were synthesized through modification of the glycine moiety of 1 and evaluated for their ability to inhibit in vitro adenosine 5'-diphosphate (ADP)-induced platelet aggregation of guinea pig platelet rich plasma (PRP). Among the compounds examined, the (3S,2S)-4-methoxyphenylalanine derivative 4h showed the most potent antagonistic activity with an IC50 value of 13 nM. Dose-dependent inhibition of ex vivo platelet aggregation was achieved with oral administration of 4h (0.3-1.0 mg/kg) to guinea pigs. Complete inhibition was observed for up to 8 h, and 43% inhibition could still be observed 24 h after oral administration of 1.0 mg/kg. The long-lasting antiplatelet effect of 4h suggests that 4h would be suitable for once-a-day dosing. Structure-activity relationships (SAR) were examined in the series of the phenylalanine derivatives. An increase in the electron density around the 4-position of the phenyl ring of the phenylalanine moiety led to an increase in the antiplatelet activity, suggesting the existence of a hydrophobic and electrostatic interaction site in addition to the ionic binding sites in the GPIIb/IIIa.

Orally active GPIIb/IIIa antagonists: synthesis and biological activities of masked amidines as prodrugs of 2-[(3S)-4

To improve the in vivo potency of the potent GPIIb/IIIa antagonist 2-[(3S)-4-[(2S)-2-(4-amidinobenzoylamino)-3-(4-methoxyphenyl)propanoyl]-3-(2-methoxy-2-oxoethyl)-2-oxopiperazinyljacetic acid (4), the amidino group was converted to an oxadiazole ring, thiadiazole ring or substituted amidoxime group. These groups were expected to be metabolized to an amidino group in vivo. The compounds synthesized were evaluated for their potency to inhibit the ex vivo adenosine 5'-diphosphate (ADP)-induced aggregation of guinea pig platelets. Among the compounds examined, the methoxycarbonyloxyamidine 8a exhibited the most potent ex vivo inhibitory activity with a fast onset and prolonged duration of action after oral administration.

A trigeminal neuralgia-like paroxysmal pain condition presumably due to buccal nerve compression in the temporalis muscle

We encountered three patients with trigeminal neuralgia-like paroxysmal pain in the buccal nerve region. In all cases, paroxysmal pain was felt spreading to the receptive field of the ipsilateral buccal nerve, and clear tenderness was observed during intraoral palpation at the inner side of the mandibular ramus where the temporalis muscle runs and attaches. It was assumed that the paroxysmal pain might be caused by nerve compression related to temporalis muscle hyperactivity. To lend support to this hypothesis, we also studied the anatomical relationship between the buccal nerve and the masticatory muscles. In this autopsy study, the buccal nerve pierced the temporalis muscle in six (12%) of 52 specimens from 26 cadavers. These findings support the hypothesis that peripheral buccal nerve compression could be an etiology of paroxysmal neuropathic pain in the unilateral orofacial region.

Neutrophils and mononuclear cells express vascular endothelial growth factor in acute Kawasaki disease: its possible role in progression of coronary artery lesions

Kawasaki disease (KD) is a syndrome of systemic vasculitis of unknown etiology that is complicated by coronary artery lesions (CAL), leading occasionally to cardiac ischemic sequelae. To examine whether vascular endothelial growth factor (VEGF) is responsible for CAL in KD, we determined serum VEGF levels by ELISA and peripheral blood mononuclear cell (PBMC) and neutrophil VEGF expression by immunoblot analysis. Significantly increased levels of VEGF were demonstrated in acute KD as well as in other vasculitis syndromes (p < 0.0001). In the 10 KD patients with CAL, serum VEGF levels were maximal approximately 2 wk post-onset when CAL generally develops and were significantly higher than in 20 patients without CAL (mean, 474 and 241 pg/mL, respectively; p = 0.00015). During the same period, immunoblot analysis revealed maximal VEGF expression in PBMC, corresponding to serum VEGF levels in most patients and being particularly marked in patients with CAL (p < 0.01). Neutrophils expressed VEGF only in the early stage of acute KD and declined rapidly in the majority of KD patients regardless of the presence of CAL, showing a strikingly different expression pattern than that for PBMC. Predominant VEGF expression by PBMC was also demonstrated in patients with other vasculitis syndromes and only faintly in normal controls. The results suggest that VEGF is generated dynamically in KD, presumably reflecting its disease activity. Neutrophil-derived VEGF may play a role in regulating early vascular responses, whereas PBMC-derived VEGF may contribute to later vascular injury and remodeling.

Design, synthesis, and 1,3-dipolar cycloaddition of (5R)- [and (5S)]-5,6-dihydro-5-phenyl-2H-1,4-oxazin-2-one N-oxides as chiral (E)-geometry-fixed alpha-alkoxycarbonylnitrones

Optically pure (5R)- [and (5S)]-5,6-dihydro-5-phenyl-2H-1, 4-oxazin-2-one N-oxides [(5R)- and (5S)-2] were designed as chiral (E)-geometry-fixed alpha-alkoxycarbonylnitrones 1. The nitrones (5R)- and (5S)-2 were synthesized by three-step oxidation of (R)- and (S)-phenylglycinols [(R)- and (S)-3], condensation of the resulting (R)- and (S)-2-hydroxylamino-2-phenylethanols [(R)- and (S)-5] with glyoxylic acid, and cyclization of the intermediary nitrones (R)- and (S)-6b. The nitrone (5R)-2reacted with olefins 7-14 under mild conditions to afford the corresponding cycloadducts 15-22 as the main products via the least sterically demanding exo modes. Cycloadduct 30 obtained from (5S)-2 and cyclopentadiene was effectively elaborated to (1S,4S, 5R)-4-benzyloxycarbonylamino-2-oxabicyclo[3.3.0]oct-7-en-3-one (28), the key synthetic intermediate of carbocyclic polyoxin C.

CD30 expression on circulating memory CD4+ T cells as a Th2-dominated situation in patients with atopic dermatitis

Th2 clones have been reported to express CD30 preferentially, but whether T cells producing Th2-type cytokines may favor CD30 expression in the in vivo state remains unknown. We investigated the expression of CD30 on circulating T cells in atopic dermatitis (AD) as a Th2-dominated disorder. Peripheral blood mononuclear cells were prepared from 51 AD patients and 14 nonatopic controls, and their phenotypes were analyzed with flow cytometry. Cytokine production by stimulated CD4+ T cells was also assessed by the single-cell-staining method. Flow cytometric analysis clearly revealed that CD30+ T cells were identifiable in the blood of AD patients with greater frequency compared to controls. The important finding was that CD30 expression was restricted to a small but substantial population of memory (CD45RO+) CD4+ T cells, but not CD8+ ones. In AD patients, it was demonstrated that the percentages of CD30+ cells within CD45RO+ CD4+ T cells correlated well with the disease severity, serum IgE levels, peripheral eosinophil counts, and tendency toward Th2-dominant cytokine pattern as determined by the ratio of interleukin-4 to interferon-gamma production. This study suggests that CD30 expression in circulating T cells might serve as an in vivo marker for the Th2-dominated condition.

Differential expression of the chemokine receptors by the Th1- and Th2-type effector populations within circulating CD4+ T cells

The in vitro studies have proposed that human Th1 cells favor expression of CXCR3 or CCR5, whereas Th2 cells favor CCR3 and CCR4. In this study, the in vivo relevance of expression of these chemokine receptors on Th cells was investigated in patients with atopic dermatitis (AD) as the Th2-dominated disorder and nonatopic normal individuals. Flow-cytometric analysis using monoclonal antibodies against CXCR3, CCR5, CCR3, and CCR4 disclosed that a substantial proportion of memory (CD45RO+) CD4+ T cells in the blood of AD and normal patients expressed CXCR3, CCR5, or CCR4, but expression of CCR3 on these cells was negligible. Stimulation studies combined with intracellular cytokine staining revealed that the cells capable of producing Th2 cytokines, such as interleukin-4 (IL-4), IL-5, and IL-13, were restricted to the CCR4-expressing population within memory CD4+ T cells. Concerning Th1 cytokine production, interferon-gamma (IFN-gamma)-producing cells resided exclusively in CXCR3-expressing memory CD4+ T cells, although IFN-gamma production was found in both memory CD4+ T cells with and without CCR5 expression. We observed that CCR4-expressing memory CD4+ T cells in the blood were more increased in AD patients as compared with normal patients, whereas CXCR3-expressing memory CD4+ T cells were present in a lower frequency in AD than seen in normal patients. These results suggest that CXCR3 and CCR4, but not CCR5 or CCR3, appear to serve as the useful markers for identification of circulating Th1 and Th2 effector populations.

Genetic defect in human X-linked agammaglobulinemia impedes a maturational evolution of pro-B cells into a later stage of pre-B cells in the B-cell differentiation pathway

Surrogate light chains (lambda 5/VpreB) are selectively expressed in early precursors of B cells. B-cell defects in X-linked agammaglobulinemia (XLA) are caused by mutations in the gene for Bruton's tyrosine kinase. To elucidate the nature of early B-lineage cells in bone marrow (BM), samples from 13 XLA patients and 24 healthy controls of different ages were comparatively analyzed using an antihuman VpreB monoclonal antibody. Expression of surrogate light (SL) and mu-heavy chains were examined after cell membrane permeabilization because they are mainly expressed in the cytoplasm of early B-lineage cells. A flow cytometric analysis of normal BM identified 5 discrete cell types of B cells: mu(-)SL(++) (pro-B [B-cell progenitor]), mu(low)SL(++) (pre-B1a), mu(low)SL(+) (pre-B1b), mu(low)SL(- )(pre-B2), and mu(high)SL(- )(B). The large cells, presumably in cycling states, were enriched in pre-B1a cells. The frequencies of B-lineage cells in BM were higher in young children, and declined with advancing age. In contrast, XLA showed a profound reduction in BM B-lineage cells. In XLA BM, an expansion of pro-B cells with some small pre-B1a cells was marked, but other cells were negligible. These observations illustrate a B-cell maturation defect in XLA as well as a normal human B-cell differentiation pathway. The results suggest that the genetic defect in XLA may impede the evolution of pro-B cells beyond the earlier pre-B stage into the later stage of pre-B cells in B-cell development. (Blood. 2000;96:610-617)

Detection of Bruton's tyrosine kinase mutations in hypogammaglobulinaemic males registered as common variable immunodeficiency (CVID) in the Japanese Immunodeficiency Registry

CVID is frequently diagnosed in male and female individuals with hypogammaglobulinaemia of unknown aetiology. To examine the possibility that sporadic male cases with X-linked agammaglobulinaemia (XLA), which is caused by mutations in the Bruton's tyrosine kinase (Btk) gene, might be misregistered as having CVID, we employed a flow cytometric test to identify XLA in hypogammaglobulinaemic males registered as CVID in the Japanese Immunodeficiency Registry. From 30 male cases registered as having CVID between 1992 and 1998, we selected 21 males with low or unreported peripheral B cell counts. Blood samples could be obtained from 11 patients and their mothers. Using flow cytometric analysis, the Btk-deficient status in monocytes was demonstrated in seven out of nine cases with decreased numbers of peripheral B cells. The diagnosis of XLA was confirmed in each of the seven patients by demonstration of Btk gene mutations in the patients or cellular mosaicism in the mother. This study demonstrates misregistration of XLA as CVID.

Large deletion of the X-linked lymphoproliferative disease gene detected by fluorescence in situ hybridization

The X-linked lymphoproliferative disease (XLP) is an inherited immunodeficiency characterized by an abnormal responses to infection with Epstein-Barr virus (EBV), resulting in fatal infectious mononucleosis, hypogammaglobulinemia, virus-associated hemophagocytic syndrome, and malignant lymphoma. Mutations in the gene coding for a T cell-specific SLAM-associated protein (SAP) have been recently identified in XLP patients. We report on a 1-year-old boy representing fulminant hemophagocytic syndrome. He developed high fever, lymphadenopathy, hepatosplenomegaly with liver dysfunction, and pancytopenia with marrow hemophagocytosis. EBV DNA was abnormally increased in the blood. Polymerase chain reaction failed to amplify SAP mRNA and genomic DNA products from the patient' As peripheral blood. A large deletion of the SAP gene was confirmed by fluorescence in situ hybridization (FISH). FISH analysis also disclosed that the patient's mother was a carrier. We conclude that FISH can be useful in the diagnosis of XLP with large deletions of the SAP gene and its carrier state.

Trapezoid bone fracture

Fractures of the carpal bones involve only a single bone or complex bones with or without ligament rupture. However, fractures of the trapezoid are rarely seen. Because the trapezoid is fastened to the trapezium, capitate, and scaphoid by strong ligaments, fracture or dislocation is limited by this rigid fixation. The authors present a single bone fracture of the trapezoid in a 40-year-old man. A tomogram of the carpal bone was useful in diagnosing the trapezoid fracture. The mechanism for development of fracture of the trapezoid alone is unknown. However, fracture of the trapezoid seemed to occur when the wrist joint was forced with excessive flexion stress that was placed on the trapezoid through the second metacarpal bone indirectly. This occurred in the same manner that a walnut is broken with nutcrackers.

Osteochondroma of the mandibular body

We have treated four cases of osseous ostechondromas arising on the mandibular body, where this tumor rarely presents on the craniomaxillofacial bones. There were no recurrences after simple surgical resection of these tumors.

Diminished expression of CD59 on activated CD8+ T cells undergoing apoptosis in systemic lupus erythematosus and Sjögren's syndrome

The present study was undertaken to examine the phenotype of T cells undergoing in vitro apoptosis in patients with autoimmune diseases such as systemic lupus erythematosus (SLE) and primary Sjögren's syndrome (SS). Compared with normal controls, we found diminished expression of CD59 antigen (one of the cell-surface complement-regulatory proteins) on CD8+ T cells, but not on CD4+ T cells, from patients with SLE and SS. Three-colour immunofluorescence analysis revealed that these CD59dim CD8+ T cells were activated T cells, expressing both human leucocyte antigen (HLA)-DR and CD45RO antigens. In addition, these CD59dim CD8+ T cells were more susceptible to in vitro apoptosis than CD59bright CD8+ T cells. In two patients with active lupus, the percentage of CD59dim CD8+ T cells was significantly decreased after steroid therapy. These findings suggest that decreased expression of CD59 antigen on in vivo-activated CD8+ T cells may be correlated with disease activity and may be involved in activation-induced apoptosis in patients with SLE and SS.

A novel technique using biplane cine magnetic resonance imaging to evaluate left ventricular volume in children

The purpose of the study is to determine the feasibility of a novel simplified technique using cine magnetic resonance imaging (MRI) to assess left ventricular (LV) volume and ejection fraction (EF) validated by comparison with biplane LV angiography. Previous MRI studies to assess LV volumes have used multiple axial planes, which are compromised by partial volume effects and are time consuming to acquire and analyze. Accordingly, we developed a simplified imaging approach using biplane cine MRI and imaging planes aligned with the intrinsic cardiac axes of the LV. We studied 20 children (aged 4 months to 10 years) with various heart diseases. The accuracy of cine MRI was compared with that of LV angiography in all patients. LV volumes were calculated using Simpson's rule algorithm, for both MRI and LV angiography. LV volumes determined from MRI were slightly underestimated but correlated reasonably well with angiographic volumes (LVEDV: Y = 0.88X + 1.58, r = 0.99, LVESV: Y = 0.73X + 1.03, r = 0.98). Most importantly, even in patients who had abnormal ventricular curvature such as in tetralogy of Fallot, MRI determined LV volumes correlated well with angiographic values. The MR study was completed within 35 min in all patients. In conclusion, simplified biplane cine MRI, using the intrinsic LV axis planes, permits noninvasive assessment of LV volumes in views comparable to standard angiographic projections and appears practical for clinical use in childhood heart disease since the scan and analysis times are relatively short.

Evaluation of pulmonary blood supply by multiplanar cine magnetic resonance imaging in patients with pulmonary atresia and severe pulmonary stenosis

The purpose of this study was to assess the capability of multiplanar cine magnetic resonance imaging (MRI) for evaluating pre- and post-operative pulmonary circulation in patients with pulmonary atresia and severe pulmonary stenosis. Seventy-three multiplanar cine MRIs were performed in 30 patients, aged 1 month to 7 years (mean age, 27 months). The morphology and size of the central pulmonary arteries (PA), source of the major aortopulmonary collateral arteries (MAPCA), patency of Blalock-Taussig (BT) shunt vessels, and the post-operative pulmonary circulation were assessed. The accuracy of cine MRI was compared with that of angiography in all patients. The PA was visualized to the first hilar branch in 21 patients, but not in 8 patients in whom the central PA was absent. On follow-up MRI, PA growth was measured, and the results showed excellent correlation with the results obtained by angiography. In 17 patients who had undergone 23 BT shunt operations, cine MRI correctly demonstrated all patient shunts and 5 of 6 stenotic lesions. Multiplanar cine MRI provided excellent detail of the peripheral PA in all patients, 7 of 8 peripheral pulmonary stenoses, 3 of 4 nonconfluent pulmonary arteries, and 2 of 3 PA obstructions. Although the sources of MAPCA were identified in 7 of 9 patients, the distal connection of the MAPCA was not detected in all patients. Seven patients were reexamined after pulmonary plasty; they exhibited normal pulmonary flow patterns. Multiplanar cine MRI provides high-resolution imaging of PA with dynamic visualization of flow and is an effective noninvasive technique for evaluating pre- and post-operative patients with pulmonary atresia and severe pulmonary stenosis.

Properties of the transient outward current in rabbit sino-atrial node cells

The electrophysiological properties of the transient outward current were investigated in voltage-clamped single cells from the rabbit sino-atrial node. To make a regional comparison, some experiments were repeated in atrial myocytes. The current-voltage relationship showed a characteristic outward rectification with an activation threshold of -30 mV. External 4-aminopyridine (0.01-5 mM) inhibited this current in a dose-dependent manner (IC50 = 0.28 mM, Hill coefficient = 1.38). The steady-state inactivation exhibited a half-maximum voltage of -35 mV and a slope factor of -.4 mV. The current density of the transient outward current was 6.3 +/- 0.5 pA/pF in sino-atrial node cells and 12.3 +/- 1.2 pA/pF in atrial cells. The inactivation time constant was faster in sino-atrial node cells (time constants 4.2 +/- 0.5 and 26.0 +/- 0.6 ms, respectively, for the fast and slow components) than in atrial cells (9.7 +/- 1.2 and 44.8 +/- 3.2 ms, respectively). Recovery from inactivation was much faster in sino-atrial node cells (time constants 44.7 +/- 9.0 ms) than in atrial cells (time constants 1.39 +/- 0.32 and 6.70 +/- 0.1 s, respectively, for the fast and slow components). These results suggest that the kinetic properties, as well as the current density, of the transient outward current differs between sino-atrial node and atrial cells. Taking the current density of Ito at +10 mV as 2.5 +/- 0.3 pA/pF gives a total Ito of approximately 100 pA at the peak of the action potential in rabbit sino-atrial node cells. The action potential duration was increased by 24.8 +/- 1.3% by 0.5 mM 4-AP. Thus, Ito may contribute significantly to the repolarization phase in mammalian sino-atrial node cells.

Macrocystic schwannoma in the seventh cervical nerve

We have recently treated a case of asymptomatic macrocystic schwannoma discovered between the left neck and the supraclavicular fossa. The tumor, originating from the left seventh cervical nerve, was extirpated. Nearly 70 percent of the tumor area showed macrocyst with transparent fluid collection. The tumor was diagnosed as macrocystic schwannoma histopathologically. Schwannoma is often associated with small cysts but rarely with macrocysts. Because schwannoma is a benign tumor, partial resection against an attempt at total removal resulting in progressive neurologic deficits is recommended. In general, schwannoma does not present any apparent symptoms at an early stage, because it occurs and progresses very slowly. Schwannoma originating at the spinal nerve root has been called a dumbbell-shaped tumor because of its characteristic shape on MRI and cystogram images. We recently have treated a case of dumbbell-shaped tumor that was an asymptomatic macrocystic schwannoma in the seventh cervical nerve.

Atypical X-linked agammaglobulinemia diagnosed in three adults

OBJECT

X-linked agammaglobulinemia (XLA) is one of the most common humoral immunodeficiencies characterized from childhood by the absence of peripheral B lymphocytes, reduced levels of serum immunoglobulins and recurrent and severe bacterial infections. These characteristics are the result of Bruton's tyrosine kinase (Btk) protein deficiency in peripheral B lymphocytes. In addition to typical XLA, several atypical cases have been recognized, who exhibited mild or even no clinical symptoms, although they were definitely deficient in Btk protein (atypical XLA). In these patients peripheral B lymphocytes and serum immunoglobulins (Igs) are detectable though at a lower level than in normal people. To clarify the discrepancies between the Btk gene mutations and the phenotypes more atypical patients should be examined. In this study we evaluated the cytoplasmic Btk protein in peripheral monocytes of some hypogammaglobulinemia adults by means of flowcytometric analysis.

MATERIALS AND METHODS

Heparinized venous blood samples were collected from some hypogammaglobulinemia adults. Mononuclear cells were separated from their blood and first reacted with a phycoerythrin-labeled CD14 monoclonal antibody (MoAb) (staining of monocyte membrane). Next, the cells were fixed and permeabilized. And then these permeabilized cells were reacted with an anti-Btk MoAb (staining of cytoplasmic Btk protein) and incubated with a FITC-conjugated goat antimouse IgG1. The double-stained cells were analyzed on a flowcytometer.

RESULTS AND CONCLUSION

By means of flowcytometric analysis we diagnosed three hypogammaglobulinemia adults as XLA, who did not show typical clinical progress of XLA. Advancements in diagnostic methods has facilitated a prompt and definite diagnosis of this disease.