Mitochondrial abnormalities in selenium-deficient myopathy

We report a man who developed selenium-deficient myopathy during long-term parenteral nutrition. Muscle biopsy showed marked mitochondrial depletion in the deep sarcoplasm and enlarged mitochondria at the periphery mainly in type 2 fibers. Muscle weakness improved gradually after the second course of selenium supplementation. The peculiar mitochondrial abnormalities in muscle fibers appear to play a key role in the pathogenesis of selenium-deficient myopathy.

Two-stage repair for aortic regurgitation with interrupted aortic arch

We performed two-stage repair for a rare adult case of interrupted aortic arch with aortic regurgitation and sinus of Valsalva aneurysm. A lateroisthmic bypass was established with minimal thoracotomy and partial clamping of the descending aorta to preserve collateral circulation. This was followed by aortic root reconstruction with a prosthetic graft and valve for aortic regurgitation with sinus of Valsalva aneurysm. This less invasive two-stage repair for such a rare pathology may facilitate smooth recovery of the patient.

Spontaneous retrograde dissection of the entire thoracic aorta originating in the abdominal aorta. Case report and review of the literature

Spontaneous retrograde thoracic extension of the abdominal aortic dissection is extremely rare and difficult to manage. Only five cases have been previously reported in the English literature (dissection reaching the ascending aorta in four, dissection limited in the descending thoracic aorta in one), and all the cases of dissection which reached the ascending aorta were lethal. We herein report one case of a 37-year-old man who was operated on for spontaneous retrograde dissection of the entire thoracic aorta originating in the suprarenal abdominal aorta. Preoperative aortogram revealed the site of the intimal tear just above the celiac artery. He urgently underwent graft replacement of the descending thoracic aorta and the abdominal aorta with reimplantation of the thoracoabdominal visceral arteries. Although the patient had to undergo the second operation for the dissection of the remaining thoracic aorta four months postoperatively, he has been doing well 18 months after the second operation.

Photodecarboxylation of DX-9065a, a new factor Xa inhibitor, in aqueous solution

The photodegradation reaction of (2S)-2-[4-[[(3S)-1-acetimidoyl-3-pyrrolidinyl]oxy]phenyl]-3- (7-amidino-2-naphthyl) propanoic acid hydrochloride pentahydrate (DX-9065a), a new factor Xa inhibitor, was investigated in aqueous solution at various pH values (1.1-8.0) at 25 degrees C. The photodegradation of DX-9065a followed apparent first-order kinetics under artificial sunlight in a fairly good manner. The photodegradation rates of DX-9065a in a neutral solution were higher than those in acidic solution. The log k-pH profile indicated that the photodegradation rate of DX-9065a was related to the dissociation of the carboxyl group and suggested that the main photo-labile species was the carboxylate form. Further kinetic study showed that the carboxylate form of DX-9065a underwent decarboxylation quantitatively to produce D41-1077, the photodecarboxylation product, on irradiation, while the carboxylic acid form of DX-9065a did not perform any photodecarboxylation. Moreover, the photodecarboxylation mechanism was discussed in relation to the kinetics and photodegradation pathway.

[Emergent operation after percutaneous transluminal coronary rotational atherectomy (ROTABLATOR)]

Emergent operations were performed in seven patients after percutaneous transluminal coronary rotational atherectomy (PTCRA). The causes of the emergent operations were coronary rupture in three patients, acute coronary occlusion in two patients, perforation of the ascending aorta in one patient and impossible weaning from IABP in one patient. IABP was used preoperatively in all patients. Coronary artery bypass grafting was performed in all patients. Ruptured sites of the coronary arteries were closed and perforated site of the ascending aorta was repaired. Two patients died due to cardiac failure but five patients were recovered. Coronary artery rupture was main complication after PTCRA. It is important to recognize the difference between the complication after PTCRA and that after conventional PTCA.

Postural dysregulation in systolic blood pressure is associated with worsened scoring on neurobehavioral function tests and leukoaraiosis in the older elderly living in a community

BACKGROUND AND PURPOSE

Postural hypotension, which occurs frequently in community-living, apparently healthy elderly adults, is usually asymptomatic. However, the relation between postural changes in blood pressure and quantitative higher cerebral function or silent brain lesions remains unclear. We examined the association of exaggerated postural changes in systolic blood pressure with cognitive and quantitative neurobehavioral functions and with brain lesions on MRI in the community-dwelling older elderly.

METHODS

The study population consisted of 334 community-dwelling elderly adults, aged 75 years or older (mean age, 80 years). Postural changes in systolic blood pressure (SBP) were assessed using an autosphygmomanometer (BP-203 I). By the difference between the mean of two measurements of SBP at standing and at supine position (dSBP = SBP at upright-SBP at supine position), we divided the subjects into three groups: (1) 20 subjects with postural hypotension (d-SBP < or = -20 mm Hg), (2) 29 subjects with postural hypertension (dSBP > or = 20 mm Hg), and (3) 285 subjects with postural normotension (20 < dSBP < 20 mm Hg). We defined the former two groups as the postural dysregulation group. Scores in four neurobehavioral function tests (Mini-Mental State Exam. Hasegawa Dementia Scale Revised, computer-assisted visuospatial cognitive performance score, and the Up and Go Test) and activities of daily living were compared among the three groups. Brain lesions on MRI, including number of lacunes and periventricular hyperintense lesions, were compared among 15 age- and sex-matched control subjects with postural hypotension, 15 with postural hypertension, and 30 with postural normotension.

RESULTS

Twenty subjects (6.0%) exhibited postural hypotension and 29 (8.7%) postural hypertension. Scores in neurobehavioral functions and activities of daily living were significantly lower in the postural dysregulation group (both postural hypotension and hypertension groups) than in the postural normotension group. The postural dysregulation group exhibited significantly more advanced periventricular hyperintensities than the normotension group.

CONCLUSIONS

Asymptomatic community dwelling elderly individuals with postural hypotension as well as those with postural hypertension had poorer scores on neurobehavioral function tests and more advanced leukoaraiosis demonstrated on MRI than those without exaggerated postural changes in SBP.

Mitral valve repair in a patient with severe porcelain aorta

We repaired the mitral valve in a patient with severe porcelain aorta. Significant mitral regurgitation developed in a 66-year-old woman with heavy calcification throughout the whole aorta. At operation, cardiopulmonary bypass was properly established by combined axillary and femoral arterial cannulations for sufficient systemic flow. Likewise, the combination of a superior mitral approach and profound hypothermic fibrillatory arrest in conjunction with low-flow cardiopulmonary bypass allowed us to repair the mitral valve successfully.

Constrictive pericarditis caused by an old hematoma

A 46-year-old woman was admitted for surgery after diagnosis of a constrictive pericarditis. She had suffered from acute pericarditis and undergone pericardiocentesis to relieve pericardial effusion several times 10 years previously. Cardiac catheterization showed elevated mean right-atrial and pulmonary wedge pressures. Chest CT revealed only a calcified mass in the retrosternal space. At surgery, there was no severe adhesion between the pericardium and the epicardium, and the pericardium was thin and almost normal except over the right artio-ventricular groove, where a hard mass with an atheromatous content adhered to the epicardium. After resection of the mass, central venous pressure and pulmonary wedge pressure decreased. The mass was found to be an old hematoma by pathological examination. The patient was subsequently discharged from hospital in good condition.

A case of homosexual murder: a victim with testicular regression syndrome

A 25-year-old male was killed with a survival knife by his business and homosexual partner. In addition to 22 wounds on the extremities, 16 wounds were found on the neck, chest and abdomen. The heart and lungs were penetrated, and three wound tracks reached the back of the body. The cause of death was diagnosed as hemorrhage. The genitalia of the victim was anomalous: the pubic hair pattern was that of a female, the penis was small and no testes were identified in the scrotal sac. According to his medical records, micropenis and bilateral cryptorchidism were present at birth, and neither hormonal treatments nor bilateral orchidopexy could enlarge his penis size. At the age of 17, his condition had been diagnosed as hypergonadotropic hypogonadism. His genital anomalies were considered due to embryonic testicular regression syndrome, and his micropenis a possible cause of his homosexual orientation. Judging from the patulous anus with thickened margins, he was probably a passive homosexual. The motive of the murder was not monetary, but rather emotional entanglement. The court judged that the case was one of premeditated murder with a short-circuited motive, and sentenced the defendant to ten years imprisonment.

Toxicological evaluation and disposition of DV-7751a, a new quinolone antimicrobial agent, administered orally to dogs and monkeys

We examined the toxic potentials and disposition of DV-7751a administered repeatedly to immature beagle dogs and mature cynomolgus monkeys. In immature dogs (n = 3) orally given DV-7751a at 5, 10 and 15 mg/kg for 8 days, arthropathy in the femur of a dog receiving 15 mg/kg was observed at termination, but not at the lower doses. Serum concentrations at 2-6 h after the 7-day treatment were 0.8-1.5, 1.2-2.1 and 1.0-2.9 micrograms/ml at 5, 10 and 15 mg/kg, respectively. In mature monkeys (n = 3) treated orally with DV-7751a at 100 mg/kg for 14 days, no toxic effects were found except for mild diarrhea throughout the experiment. Serum concentrations at 2 to 4 h after the final treatment were 8.3 to 11.4 micrograms/ml. In both species, there were no significant differences in the serum drug concentration between the first and last (repeated) administration, indicating no drug accumulation. In monkeys, hydrolysis of the urine sample showed no effect on the concentration of DV-7751a, whereas that of the bile sample displayed a significant increase in its concentration, demonstrating that conjugated forms may be secreted into bile. This was confirmed by a thin-layer chromatogram-bioautogram, and at least two kinds of active metabolites including a polar substance seemed to exist in bile. These results raise the possibility that DV-7751a possesses joint toxicity, but dose not show any effect on the hepatic function under conditions of this study.

[Emergent coronary artery bypass grafting in a patient with mirror-image dextrocardia]

A 49 year-old-man with known situs inversus totalis was admitted to our hospital with a history of angina pectoris of 4 months duration. Coronary arteriography revealed that the left main trunk had a 90% stenosis. After the arteriography, the patient's hemodynamics was deteriorated, and he required a support of intraaortic balloon pumping. He underwent emergent coronary artery bypass grafting with saphenous veins the following day, and recovered uneventfully. Technical problems in this patient from a surgical viewpoint were discussed. As far as we know, this is the first case of coronary bypass grafting on a patient with mirror-image dextrocardia and a stenosis of the left main trunk.

Japanese families with autosomal dominant pure cerebellar ataxia map to chromosome 19p13.1-p13.2 and are strongly associated with mild CAG expansions in the spinocerebellar ataxia type 6 gene in chromosome 19p13.1

Autosomal dominant cerebellar ataxia is a group of clinically and genetically heterogeneous disorders. We carried out genomewide linkage analysis in 15 families with autosomal dominant pure cerebellar ataxia (ADPCA). Evidence for linkage to chromosome 19p markers was found in nine families, and combined multipoint analysis refined the candidate region to a 13.3-cM interval in 19p13.1-p13.2. The remaining six families were excluded for this region. Analysis of CAG-repeat expansion in the alpha1A-voltage-dependent calcium channel (CACNL1A4) gene lying in 19p13.1, recently identified among 8 small American kindreds with ADPCA (spinocerebellar ataxia type 6 [SCA6]), revealed that 8 of the 15 families studied had similar, very small expansion in this gene: all affected individuals had larger alleles (range of CAG repeats 21-25), compared with alleles observed in neurologically normal Japanese (range 5-20 repeats). Inverse correlation between the CAG-repeat number and the age at onset was found in affected individuals with expansion. The number of CAG repeats in expanded chromosomes was completely stable within each family, which was consistent with the fact that anticipation was not statistically proved in the SCA6 families that we studied. We conclude that more than half of Japanese cases of ADPCA map to 19p13.1-p13.2 and are strongly associated with the mild CAG expansion in the SCA6/CACNL1A4 gene.

[Coronary artery bypass surgery in aged patients]

From January 1993 through December 1996, 749 patients underwent isolated coronary artery bypass grafting. Of these patients, 578 patients were older than 60 years old. We classified them into three groups; Group A were the 60 to 69 year age group (337 patients), Group B were the 70 to 79 year age group (224 patients) and Group C were over 80 years age group (17 patients). Emergency cases and preoperative LV dysfunction cases were more frequently in Group C, but mortality did not differ among three groups. Duration of intubation, ICU stay and hospital stay were longer in Group C than other groups and complications (PMI, arrhythmia and reoperation for bleeding) were more frequently in Group C. Coronary artery bypass surgery can be performed in aged patients, especially for patients over 80 years old, with acceptably low mortality and significant functional benefit but a high incidence of complications necessitates careful postoperative management in aged patients.

Unusual post-mortem autolytic change in the liver: wavy transformation of hepatocytes

An unusual morphologic change noted in the liver of a 21-year-old male who committed suicide by taking dimenhydrinate is described. The post-mortem interval was two days. Microscopically, there were no marked ante-mortem pathologic changes. In addition to the unusual post-mortem autolytic changes, such as disappearance of the hepatic cords and shrinkage of the hepatocytes, conspicuous way transformation of the hepatocytes, which was apparently never been reported before, was observed. This change could not be identified as an artifact, and it was assessed to be a type of autolysis.

Contribution of cytochrome P450 3A pathway to bromocriptine metabolism and effects of ferrous iron and hypoxia-re-oxygenation on its elimination in the perfused rat liver

The contribution of the cytochrome P450 3A pathway to bromocriptine metabolism, and the effects of ferrous iron and hypoxia-re-oxygenation on its elimination, were evaluated with the perfused rat liver. Outflow profiles of bromocriptine after bolus administration were estimated by moment analysis and dispersion model analysis. Kinetic parameters were not significantly changed by troleandomycin, a P450 3A inhibitor. The inhibition of bromocriptine metabolism by troleandomycin was 5.7 +/- 2.4%. These findings indicate that cytochrome P450 3A does not play an important role in bromocriptine elimination with the perfused rat liver. Elimination rate constant (ka) values were significantly increased by ferrous iron perfusion or hypoxia-re-oxygenation. Free-radical generation can, therefore, affect bromocriptine elimination. Our observations suggest that bromocriptine might be eliminated by scavenging of free radicals in the liver.

Surgical management of aortic regurgitation associated with ventricular septal defect

Surgical treatment for congenital aortic regurgitation (AR) with ventricular septal defect (VSD) in pediatric patients carried out between 1979 and 1994 was reviewed. Aortic commissural valvuloplasty (AVP) was performed on prolapsed cusps in 34 patients (mean age 6.3 +/- 3.3 years (range: 2 to 24 years) with AR and VSD. The preoperative grade of AR was 2.6 +/- 0.8 measured angiographically by Sellers' classification. Patients had greater than moderate AR in conjunction with subpulmonary (n = 16), perimembranous (n = 15) or mixed type VSD (n = 3). In total, 25 right coronary cusps (RCC), five non-coronary cusps (NCC) and one left coronary cusp were repaired. In two cases, both RCC and NCC were plicated. One case had bicuspid valve and both cusps were repaired. There were no operative or late deaths. Moreover, the AR grade of the 25 cases has been below mild during a mean of 11.3 years follow up, though seven cases (22%) have developed above moderate AR. The two cases with persistent AR required redo AVP, with one having aortic valve replacement eventually after redo surgery. The operative findings showed cusp perforation on the repair site, or cusp elongation. However, the overall event-free rate analyzed by the Kaplan-Meier method was sufficiently favorable, with 96.6 +/- 3.4% for 5 years and 92.8 +/- 4.9% for 10 years. We conclude that aortic valvuloplasty for aortic regurgitation and VSD in pediatric patients is beneficial, with low mortality and reoperation rates.

Effects of nifedipine and enalapril on cardiac autonomic nervous function during the tilt test in elderly patients with hypertension

To clarify the effects of nifedipine and enalapril on cardiac autonomic nervous function during postural changes, power spectral analysis of heart rate variability and humoral factors was performed during tilt tests before and after 3 months of drug administration. The study group consisted of 29 elderly patients with hypertension (mean age, 69 yr), who were divided into two groups: 15 patients received nifedipine (group N) and 14 received enalapril (group E). In group N, systolic blood pressure was significantly decreased and the percent changes in low-frequency coefficient of component variance, normalized low-frequency: high-frequency ratio, and plasma norepinephrine concentration were significantly altered by nifedipine administration. Group E, in contrast, showed no significant decrease in SBP, and only the percent change in high-frequency coefficient of component variance increased significantly after enalapril administration. These results suggest that cardiac autonomic nervous function is markedly impaired during the tilt test after long-term treatment with nifedipine, whereas it is well-maintained after long-term treatment with enalapril.