Trapdoor thoracotomy as a surgical approach for aortic arch aneurysm

Since 1991 ten patients, 9 male and 1 female, with aortic arch aneurysm underwent surgical therapy with trapdoor thoracotomy. The mean age was 67.4 +/- 9.1 (standard deviation) years at operation. In addition to the aortic arch repair, we also performed seven descending aortic replacements. We performed one partial arch replacement, one total arch replacement, and one aneurysmorrhaphy and wrapping of the aortic arch aneurysm. We experienced 1 case of paraplegia, no hospital death, and no long-term mortality.

Cryoglobulinaemia among maintenance haemodialysis patients and its relation to hepatitis C infection

It has been shown that hepatitis C virus (HCV) infection is closely associated with mixed type cryoglobulinaemia. It is also known that HCV infection is rampant among chronic haemodialysis patients. We studied 531 renal failure patients on maintenance dialysis including 170 with positive HCV antibodies for cryoglobulinaemia, and its incidence was compared with controls which consisted of 242 chronic hepatitis C patients without renal failure and 183 healthy adults. Cryoglobulinaemia was present in 30.6% of dialysis patients with HCV infection, 10.8% of dialysis patients without HCV infection, 29.8% of patients with chronic hepatitis C without renal failure, and 0% of healthy adults. Among the 30 new renal failure patients who were started on dialysis within 6 months, four were positive for HCV antibodies, and one of them had cryoglobulinaemia; of the 26 HCV-negative patients, four (15%) were cryoglobulinaemic. The cryocrit values among dialysis patients were much lower than those of the control cases and other reports on non-dialysis cases. Patients with cryoglobulinaemia were generally younger compared with patients negative for this condition. There was no correlation between cryoglobulinaemia and past blood transfusion, underlying disease or length of dialysis. Cryoglobulinaemic patients seem to develop renal failure at relatively young ages and a considerable proportion of cryoglobulinaemic dialysis patients may have already had cryoglobulinaemia at the time of the start of haemodialysis. There was no indication that the presence of cryoglobulin in serum adversely affects the liver disease nor increases serum virus load in HCV-infected dialysis patients. Thus, it was concluded that although HCV infection has a certain role in the development of cryoglobulinaemia in dialysis patients, they develop cryoglobulinaemia less frequently and produce cryoglobulin to a lesser degree in the presence of HCV infection as compared with non-dialysis patients.

[A case report of mitral valve replacement using a parasternal incision (minimally invasive cardiac surgery) with pleuritis tuberculosa and after esophagus operation]

A 68-year-old man underwent mitral valve replacement because of mitral regurgitation (prolaps of anterior mitral leaflet) using parasternal incision (Delos M. Cosgrove, minimally invasive surgery). He had been treated as pulmonary tuberculosis previously and had undergone esophagus operation using stomach role reconstruction beneath the sternum four years before the mitral valve procedure. We could not select median-sternotomy as an approach due to stomach role beneath the sternum, nor left posterolateral thoracotomy because of the heavy left-side pleural adhesion. Cardio-pulmonary bypass cannulations were performed through the same incision, because severe atherosclerosis was found at the distal arteries of the abdominal aorta.

Acute hepatitis C among renal failure patients on chronic haemodialysis

Hepatitis C virus (HCV) infection is common in haemodialysis units, yet little information is available about the clinical feature of acute hepatitis C among renal failure patients. The present study is based on 49 cases of acute hepatitis C seen at a haemodialysis centre where sporadic nosocomial infection was occurring up to June 1993. Liver function tests were done at 4 weekly intervals on all dialysis patients, anti-HCV antibodies were tested by the C-100 and second generation tests and serum HCV-RNA was determined by the branched DNA and Amplicore tests. Diagnosis of acute hepatitis C was made on the basis of an acute rise in alanine aminotransferase (ALT) and seroconversion to positive anti-HCV antibodies. Clinical presentation of acute hepatitis was generally mild with rare overt jaundice and the diagnosis was possible only from increased ALT, which was generally low. Spontaneous resolution of acute hepatitis within 8 months with clearance of viral RNA occurred in only four cases, 91.8% of patients developing chronic hepatitis. Biopsy in 12 cases with high ALT levels showed mild to moderate inflammatory activities. In conclusion, the clinical presentation of acute hepatitis C is generally mild in chronic haemodialysis patients, but spontaneous resolution is infrequent. A longer follow-up period is required for defining the long-term prognosis.

[The comparison of tepid and moderate hypothermic cardiopulmonary bypass in cardiac surgery]

Normothermic cardiopulmonary bypass (CPB) is being increasingly used at some institutions. Patients undergoing normothermic CPB have a higher systemic oxygen demand and may be at higher risk for ischemic injury. This study was designed to confirm the clinical efficacy and safety of tepid hypothermic CPB. Thirty-six patients undergoing open heart surgery between June 1993 and August 1994 were divided into two groups: tepid (n = 18, 32 degrees C) and moderate (n = 18, 26 degrees C) hypothermic CPB. There were no significant differences in preoperative and perioperative patients characteristics between the two groups. The mean aortic cross-clamp time did not differ between two groups, but the mean CPB time was significantly shorter in tepid hypothermic patients. Serum lactate after CPB and lactate/pyrvate ratio during CPB in tepid hypothermic patients were significantly lower than in moderate hypothermic patients. The mixed venous oxygen saturation in tepid hypothermic patients was significantly lower however, it was maintained at levels more than 70% during CPB. This study suggests that tepid hypothermic CPB is a safe and effective alternative to moderate hypothermic CPB for patients undergoing open heart surgery. Previous reports have documented that patients undergoing normothermic CPB are at greater risk for cerebral desaturation. We should evaluate cerebral venous oxygen saturation during tepid hypothermic CPB before the induction of normothermic CPB.

GB virus-C infection among chronic haemodialysis patients: clinical implications

It is known that patients on chronic haemodialysis are frequently infected with hepatitis C virus (HCV). It has recently been found that GB virus-C (GBV-C) and hepatitis G virus frequently coinfect patients with HCV. This study aimed at elucidating the clinical implications of GBV-C infection among haemodialysis patients who have and do not have HCV infection. GBV-C RNA was detected in sera of randomly selected 98 anti-HCV-positive and 85 -negative patients on dialysis by reverse transcription-polymerase chain reaction using two sets of amplification primers made from the reported sequences of the non-structural protein 3 and 5' untranslated regions. In these patients, liver function tests were carried out at regular intervals. There were six patients who were coinfected with HCV and GBV-C and three who had only GBV-C RNA. All had a history of past blood transfusion. The onset of mild hepatitis was identified in three HCV-negative patients; elevation of alanine aminotransferase (ALT) following blood transfusion was very mild but recognizable, and aspartate aminotransferase (AST) was higher than ALT. In two of six coinfected patients, the onset of liver disease was recognized with a peak ALT of 72 and 90 IU/L, respectively. Two of these six were Amplicore (HCV-RNA) negative and asymptomatic, two had low-grade HCV viraemia and two moderate-grade HCV viraemia. Of the 98 anti-HCV-positive cases, 41 were thought to have had nosocomial infection of HCV or non-A, non-B virus; none of them had GBV-C. GBV-C RNA was negative in nine patients who had chronic non-A-E hepatitis. GBV-C infection was detected in 6.1% of anti-HCV-positive and in 3.5% of -negative dialysis patients. All had blood transfusion in the past, and there was no evidence of patient-to-patient spread of GBV-C in hospital. The liver disease was very mild and self-limited in GBV-C infection alone. The natural history of coinfected patients may be similar to that of those with chronic HCV infection, but the liver disease appears to be milder.

Analysis of the T beta gamma-binding domain of MEKA/phosducin

MEKA/phosducin, a 33 kDa phosphoprotein in the photoreceptor cell, associates with transducin beta gamma (T beta gamma) with its N-terminal domain (N-terminal 105 amino acids of MEKA), and translocates T beta gamma from the photoreceptor disc membrane to the soluble fraction. The present study further localized the T beta gamma-binding domain to aa 17-105 of MEKA, and showed that the activity of MEKA to translocate T beta gamma depends on the domain. A series of deletion mutant MEKA proteins were prepared to investigate the domain of MEKA which binds to and translocates T beta gamma. Both binding and translocation activities were not impaired by the deletion of the N-terminal 16 amino acids of MEKA, but completely abolished by further deletion to 42Val. Although anti-MEKA serum inhibited the T beta gamma-MEKA association, the antiserum absorbed with a recombinant peptide corresponding to aa 17-105 of MEKA did not, confirming that aa 17-105 of MEKA directly interacts with T beta gamma.

Adsorption of hepatitis C virus particles onto the dialyzer membrane

It was recently found that the blood level of hepatitis C virus (HCV) RNA is significantly reduced after each dialysis procedure in patients on chronic hemodialysis. This study was designed to elucidate the mechanism for this phenomenon. In two patients with high serum levels of HCV RNA, the filtrate through the dialyzer (TF-alpha, Teijin Co., Tokyo, Japan) was analyzed for viral RNA using the polymerase chain reaction. At the end of dialysis, the filter was washed with saline, and during the saline washing, aliquots were taken for quantification of RNA by the branched DNA method. The HCV core antigen was quantified as a measure of viral particles, and hemoglobin was also measured for correcting for blood contamination. After the clearance of the blood, the filter was washed with guanidinium isothiocyanate, and the recovery of RNA was measured. The filtrate did not contain detectable RNA. The saline washing of the filter after dialysis contained a significant amount of RNA. Washing with guanidinium isothiocyanate of the thoroughly saline washed filter also recovered a significant amount of RNA. During saline washing, the recovery of RNA in the washing was much delayed behind that of hemoglobin, suggesting the adsorption of the former onto the filter membrane. There was a discordant recovery of RNA and HCV core antigen in the washing, the recovery of the former being delayed behind that of the latter. These results indicate that viral particles are adsorbed onto the inner surface of the filter membrane during dialysis. Some of these adsorbed viral particles are perhaps destroyed by hydraulic pressure applied to blood for dialysis.

Antibiotic MICs and short time-killing against Helicobacter pylori: therapeutic potential of kanamycin

We compared the susceptibility of Helicobacter pylori to several antibiotics, expressed as MICs and as bactericidal effectiveness in short (3 h) time-killing studies. Of the antimicrobial agent tests, clarithromycin and amoxycillin had the lowest MIC50, 0.063 and 0.125 mg/L respectively, for 24 strains of H. pylori. Minocycline, levofloxacin and lansoprazole followed, with MIC50s of 0.5, 1, and 2 mg/L, respectively. Three-hour time-killing studies using a standard strain demonstrated a different pattern. At 4 x MIC, kanamycin, metronidazole and clarithromycin produced 4.4, 2.6 and 2.1 log decreases in viability, whereas the remaining seven antibiotics (including amoxycillin) were less bactericidal. Amoxycillin's lack of bactericidal activity during brief incubations was confirmed by examining several different clinically isolated H. pylori strains. Clarithromycin's effect, on the other hand, was strain- and concentration-dependent. Kanamycin was the most potent antibiotic in short time-killing studies, with concentrations of 1 x MIC and 4 x MIC producing a reduction of more than 2 and 4 log respectively in all ten strains. Our data suggest that the MIC of antimicrobial agents against H. pylori does not necessarily predict their activity in short time-killing studies. Furthermore, our short time-kill data suggest kanamycin as a potential therapeutic choice for H. pylori infection, even though this agent's MIC would suggest limited activity.

Characterization of a nuclear factor that enhances DNA binding activity of SSCRE-BP/PUR alpha, a single-stranded DNA binding protein

Pur alpha has been identified as a single-stranded DNA binding protein that specifically binds to the purine-rich strand present in the DNA replication initiation zone of the human c-myc gene. We have previously demonstrated that chronic morphine treatment decreases the DNA binding activity of ssCRE-BP (single-stranded cyclic AMP response element-binding protein), which has been shown to be identical to pur alpha by cDNA cloning, and is abundant in the brain. In this report we identified an activator of ssCRE-BP/pur alpha in the brain and characterized it. Although purified ssCRE-BP/pur alpha or its GST-fusion protein exhibited very low DNA binding activities, they were markedly enhanced by including nuclear extract in the binding assay. The enhanced binding activity is trypsin-sensitive, heat-stable and has a molecular weight of approximately 66 kDa. Casein could substitute for the activator and increased the DNA binding activity of ssCRE-BP/pur alpha by one order. A series of deletion mutants were prepared in order to determine the DNA binding and activator interacting domains, and both of them were found to reside in AA 50-215 of ssCRE-BP/pur alpha. These data suggest that the DNA binding activity of ssCRE-BP/pur alpha is augmented by a nuclear protein, which may modulate the ssCRE-BP/pur alpha activity to develop morphine dependence and tolerance.

[A case of primary anterior mediastinal liposarcoma with a heterotopic mass in the pericardium of the same histology]

We experienced a case of primary anterior mediastinal liposarcoma with a heterotopic mass in the pericardium of same histology. Twenty reported cases in Japan were also studied. The patient was a 50-year-old male who visited the hospital because of an abnormal shadow on a chest X-ray. The diagnosis of anterior mediastinal tumor was confirmed by a chest CT. The patient underwent a complete resection of the mediastinal and intrapericardial masses. The histologic diagnosis was a well differentiated liposarcoma of Enzinger's classification. No evidence of recurrence or metastasis was detected in the third postoperative year. Liposarcoma is rarely seen in the mediastinum. Since radiotherapy and chemotherapy are ineffective therapeutic modalities, surgery would be the treatment of choice and complete surgical resection is mandatory.

Involvement of a single-stranded DNA binding protein, ssCRE-BP/Pur alpha, in morphine dependence

We have purified a nuclear protein from mouse cerebella that binds to single-stranded oligo-DNA of cAMP response element and is modulated by morphine treatment. Isolation of the cDNA clone showed that the nuclear protein (ssCRE-BP) was identical to Pur alpha, a DNA binding protein for single-stranded purine-rich sequences that was originally isolated as a replication factor. ssCRE-BP/Pur alpha and mRNA were abundant in the brain. The levels of ssCRE-BP/Pur alpha and the transcript were not changed by chronic morphine treatment, however, the levels of an activator of ssCRE-BP/Pur alpha, which is necessary for the DNA binding, may be modulated by the treatment.

MEKA/phosducin attenuates hydrophobicity of transducin beta gamma subunits without binding to farnesyl moiety

Hydrophobic modifications of transducin (T) gamma, such as farnesyl-and carboxyl-methylation, are essential for the association of T beta gamma with the photoreceptor disc membrane, and MEKA/phosducin is known to inhibit the association. In this study, we examined the effect of MEKA on the hydrophobicity of T beta gamma. MEKA could bind to T beta gamma without farnesyl/carboxyl-methyl moieties as well as native T beta gamma. In the Triton X-114 phase separation assay, T beta gamma-MEKA complex was recovered in the aqueous phase, whereas T beta gamma was recover in the detergent phase. N-terminal portion of MEKA which includes T beta gamma-binding domain was not sufficient to reduce the hydrophobicity of T beta gamma or to dissociate T beta gamma from the membrane. The data suggest that MEKA attenuates the hydrophobicity of T beta gamma to result in the dissociation of T beta gamma from the membrane without directly binding to farnesyl/carboxyl-methyl moieties.

[A surgical case report of angina pectoris with multiple coronary giant aneurysms]

A 47-year-old man with sever angina pectoris was referred for surgery. Preoperative coronary angiogram revealed giant multiple aneurysms of RCA (Seg 1-Seg 3) and LCX (Seg 11) and LAD (Seg 6). Stenoses were found distal to aneurysm, 90% in RCA-Seg 4, CX-Seg 11, 100% in LAD- Seg 6 and DX-Seg 9 and OM-Seg 12, with collaterals from RCA to LAD. Left ventlicle contracted poorly with the EF of 36 due to anteroseptal infarction. Coronary artery bypass grafting were performed to LAD using a LITA, to DX and LCX using a SVG in the sequential fashion. Postoperative coronary cineangiogram demonstrated that all grafts were patent and multiple giant coronary aneurysms resembled coronary arterial changes of Kawasaki's disease.

Generation of vibrational and rotational emissions by four-wave Raman mixing using an ultraviolet femtosecond pump beam

A femtosecond KrF excimer laser is focused into molecular hydrogen to generate a multifrequency laser beam, consisting of many vibrational and rotational lines, in a transient Raman regime. The intensity distribution is unchanged from 5 to 13 atm, in contrast to the case of nanosecond laser pump. The efficiency for generation of the rotational lines is improved by increasing the peak power, especially at longer wavelengths, indicating power-dependent and wavelength-dependent behavior of this effect, as expected from theory.

Hypoaminotransferasemia in patients undergoing long-term hemodialysis: clinical and biochemical appraisal

BACKGROUND & AIMS

It has been reported that patients with chronic renal failure have low serum aspartate aminotransferase (AST) and alanine aminotransferase (ALT) levels as a result of vitamin B6 deficiency. Chronic hepatitis C is common among patients undergoing hemodialysis, and low aminotransferase levels cause diagnostic problems. The aim of this study was to determine the cause of hypoaminotransferasemia.

METHODS

Serum levels of vitamin B6 and its coenzyme were reassessed in relation to AST and ALT levels in patients undergoing long-term hemodialysis using high-performance liquid chromatography.

RESULTS

The mean (+/- SD) serum AST and ALT levels in 304 patients negative for hepatitis B surface antigen and anti-hepatitis C virus were 9.2 +/- 2.4 and 7.4 +/- 1.7 IU/L, respectively. In 556 normal adults, they were 22.7 +/- 5.4 and 18.0 +/- 4.0 IU/L, respectively (P < 0.001). Mean serum vitamin B6 and pyridoxal-5'-phosphate levels in patients undergoing dialysis were not reduced compared with the control, although occasionally patients had low levels. The AST and ALT assay reagents in Japan do not contain added pyridoxal-5'-phosphate; addition of pyridoxal-5'-phosphate (0.1 mmol/L) to the reagent significantly increased measurements to similar extents in both groups.

CONCLUSIONS

Serum AST and ALT levels in patients undergoing dialysis are very low, but they are not a result of vitamin B6 deficiency. The upper normal limits of AST and ALT levels in patients undergoing dialysis should be reduced considerably, and these levels should be interpreted with caution in the diagnosis of liver disease.

Interferon treatment for chronic hepatitis C in haemodialysis patients: suggestions based on a small series

Chronic hepatitis C is endemic among chronic haemodialysis patients. There have been a number of reports on hepatocellular carcinoma developing in such patients in Japan. The present study reports on the treatment of 15 patients who showed elevated ALT levels due to biopsy proven chronic hepatitis C with interferon alpha-2a (IFN). The dose schedule was 6 mega units (MU) daily for the first two weeks followed by 3 doses per week for 5.5 months. Side effects were so severe that IFN treatment was discontinued early in one patient, the dosage reduced in 11 and only tolerated in the original schedule by three patients. Excluding one patient who only recently completed the therapy, 13 were able to be evaluated for therapy efficacy by assessment of serum ALT and viral RNA. The overall results showed that IFN was effective in eight of 13 patients, a rate somewhat higher than the reported figures in this country. It is concluded that IFN therapy is indicated in haemodialysis patients with progressive chronic hepatitis C, but the dose administered should be lower and the dose schedule more flexible, perhaps 3 MU three times a week, in order to minimize untoward side effects.

Mode of hepatitis C infection not associated with blood transfusion among chronic hemodialysis patients

In a retrospective study carried out on about 730 patients with chronic renal failure who underwent ambulatory hemodialysis from January 1991 to June 1994, 49 patients were found to have developed acute hepatitis C, as confirmed by seroconversion for anti-HCV antibodies without blood transfusion in the preceding 6-month period. Epidemiological survey disclosed that two patients undergoing dialysis at consoles separated by one console developed acute hepatitis C in October 1992, and another three patients at adjacent consoles also developed acute hepatitis C within 2 weeks in April/May, 1993. It was found that some negligent nurses could have withdrawn needles from these patients one after another without changing gloves at the termination of the dialysis procedure. After reeducation of the staff members and introduction of a new type of adhesive pad to be placed on the needle wounds at the time of needle withdrawal, no new case of acute hepatitis C occurred for more than 1 year, suggesting nosocomial spread of HCV infection among hemodialysis patients in a mode that is preventable with very strict aseptic precautions.

A novel E250X mutation of the PIT1 gene in a patient with combined pituitary hormone deficiency

PIT1 abnormality is defined as a genetic abnormality in the PIT1 gene that encodes a pituitary specific transcription factor, Pit-1/GHF-1. PIT1 abnormality indicates combined deficiency of thyrotropin (TSH), growth hormone (GH) and prolactin (PRL), and has been reported in several cases. We studied the PIT1 gene in a patient with combined deficiency of TSH, GH and PRL. A novel mutation substituting a termination codon for Glutamate at 250th codon (E250X) was identified in the homozygous state in the patient. Both of the healthy parents harbored this mutation in the heterozygous state. This nonsense mutation results in complete loss of helix 3 of the POU homeodomain of Pit-1/GHF-1. As helix 3 of the homeodomain is involved directly in DNA binding, the mutant Pit-1/GHF-1 may lose the DNA binding activity of the POU homeodomain and lose its transcriptional activation. The E250X mutation is therefore considered to be the cause of the combined deficiency of TSH, GH and PRL in this patient.

Screening for PIT1 abnormality by PCR direct sequencing method

PIT1 abnormality is defined as a genetic abnormality in the PIT1 gene, which encodes a pituitary specific transcription factor Pit-1/GHF-1.PIT1 abnormality has been reported in several patients displaying either complete or incomplete deficiency of thyrotropin (TSH), growth hormone (GH), and prolactin (PRL) in either familial or sporadic cases. To see if there are abnormalities in the PIT1 gene in patients with incomplete TSH, GH, and PRL deficiency, we utilized a PCR direct sequencing method to determine the Pit-1/GHF-1 coding sequence. A total of 15 patients, 1 patient from a family with TSH and GH deficiency, 3 patients with TSH, GH, and PRL deficiency, and 11 patients treated with both human GH (hGH) and thyroid hormone were studied. In one patient of combined pituitary hormone deficiency, the Arg-271-Trp mutation was detected. Since both of the parents did not harbor this mutation, it is a de novo germ line mutation. No mutation was detected in the other patients, showing that PIT1 abnormality is not a frequent cause of GH deficiency.

[Mitral obstruction due to infective endocarditis: a case report]

Acute valvular obstruction caused by vegetation is a rare complication infective endocarditis. To our knowledge, only 9 cases and an autopsy case by Roberts have been reported since 1967. A 46-year-old man admitted with a chief complaint of pyrexia for 2 months duration. Within 24 hours of admission, the patient noticed of increased shortness of breath. Physical examination and the chest X-ray confirmed the pulmonary edema. An echocardiogram revealed a huge echogenic mass that was adherent to the mitral leaflet and obstructed the orifice completely. Soon after the patient fell into cardiogenic shock, an emergency mitral valve replacement was undertaken. At operation, multiple verrucae arising from the entire mitral leaflet was seen to occlude the orifice. The vegetation was excised and replaced with a # 25 Omnicarbon prosthesis. Postoperatively, the patient developed multiple organ failure caused by cardiogenic and septic shock which responded well to intensive medical treatment consisting of hemodialysis and continuous arteriovenous hemofiltration. Angiographically, a mycotic aneurysm in the left radial artery was found on the 18th postoperative day. After extirpation of the infective focuses, the postoperative course had stabilized. Mitral obstruction due to infective endocarditis is a fatal disease. Prompt diagnosis with echocardiogram and an emergency surgery should be undertaken to save the patient.