A vascular ring: right aortic arch and descending aorta with left ductus arteriosus

A case is presented of vascular ring caused by right aortic arch with mirror-image branching and left ductus arteriosus. In this case, the descending aorta was located right of the tracheoesophagus and the left ductus arteriosus connected to the descending aorta far below the arch, producing compression of the esophagus only. Through median sternotomy, the ligation and division of the ductus was performed with concomitant repair of ventricular septal defect.

Application of computerized image analysis in pigmentary skin diseases

BACKGROUND

Melanocyte number and the amount of melanin pigment are related to diagnosis and treatment of pigmentary skin diseases. Various histologic methods are used, such as Fontana-Masson stain for melanin pigment or immunohistochemical stain for melanocytes. Recently, computerized image analysis has been applied to many fields to avoid interobserver bias. In this study, we applied a computerized image analysis to assess the melanin content and melanocyte density of human epidermis.

METHODS

We evaluated the skin biopsy specimens (paraffin blocks) from normal human skin (33 +/- 6.6, n = 11) and diseased skins; vitiligo (32 +/- 10.0, n = 8), melasma (35 +/- 8.6, n = 11), and lentigo senilis (40 +/- 7.2, n = 11) (mean age +/- SD). Each specimen was stained with Fontana-Masson for melanin pigments and immunohistochemical method for melanocytes. Quantitative analysis of melanin pigment and melanocyte number (density) were investigated through two methods: (1) two dermatologists measured the visual scales; and (2) computerized image analysis was used to measure melanin content indices (MCI). The data were evaluated using one-way ANOVA.

RESULTS

The visual scale of the Fontana-Masson stain was the highest for lentigo senilis (3.8 +/- 0.40), followed by melasma (2.6 +/- 0.67), normal skin (1.8 +/- 0.60) and vitiligo (0) (P < 0.05). These findings were consistent with objective measurements made by computerized image analysis. MCI values were 120.3 +/- 20.74 for lentigo senilis, 81.1 +/- 19.27 for melasma, 45.5 +/- 16.92 for normal skin, and 0.3 +/- 0.30 for vitiligo in decreasing order (P < 0.05). MC/1E (melanocyte number per 1 mm epidermis) was about two fold larger in lentigo senilis (18.1 +/- 8.92) than melasma (9.7 +/- 2.40) or normal skin (9.3 +/- 2.67) (P < 0.05). MC/1B (melanocyte number per 1 mm basal layer) was about 1.5 fold higher in lentigo senilis (13.5 +/- 4.17), compared to normal skin (9.0 +/- 3.55) (P < 0.05). Melasma showed increased melanocyte numbers compared to normal skin, but it was not statistically significant (P > 0.05).

CONCLUSION

We believe this computerized image analysis could be useful tool for diagnosis and comparison of interval changes in pigmentary diseases like melasma or lentigo senilis by quantifying melanin pigments or melanocytes in skin biopsy specimens.

Haloperidol-induced neuronal apoptosis: role of p38 and c-Jun-NH(2)-terminal protein kinase

We examined patterns and mechanisms of cell death induced by haloperidol. Cortical cell cultures exposed to 10-100 microM: haloperidol for 24 h underwent neuronal death without injuring glia. The degenerating neurons showed hallmarks of apoptosis, featuring cell body shrinkage, nuclear chromatin condensation and aggregation, nuclear membrane disintegration with intact plasma membrane, and prominent internucleosomal DNA fragmentation. Neither glutamate antagonists nor antioxidants prevented the haloperidol-induced neuronal apoptosis. The c-Jun-NH(2)-terminal protein kinase and p38 mitogen-activated protein kinase were activated within 1 h and were sustained over the next 3 h following exposure of cortical neurons to 30 microM haloperidol. Haloperidol-induced neuronal apoptosis was partially attenuated by 10-30 microM PD169316, a selective inhibitor of p38 mitogen-activated protein kinase. Inclusion of 1 microg/ml cycloheximide, a protein synthesis inhibitor, or 100 ng/ml insulin prevented activation of both kinases and subsequent neuronal death. The present study demonstrates that cortical neurons exposed to haloperidol undergo apoptosis depending on activation of p38 mitogen-activated protein kinase and c-Jun-NH(2)-terminal protein kinase sensitive to cycloheximide and insulin.

NT-4/5 exacerbates free radical-induced neuronal necrosis in vitro and in vivo

Neurotrophins render neurons highly vulnerable to certain injuries. We examined the possibility that NT-4/5 would enhance free radical neurotoxicity in vivo as well as in vitro. Striatal neurons exposed to 10 microM Fe(2+) or 1 mM l-buthionine-[S, R]-sulfoximine (BSO) underwent mild degeneration within 24 h. With concurrent addition of 10-100 ng/ml NT-4/5, neuronal death following exposure to Fe(2+) or BSO was significantly increased and suppressed by addition of 100 microM trolox, an antioxidant. In the adult brain, the intrastriatal injections of 20 nmol Fe(2+) revealed features of neuronal necrosis such as swelling cell body and mitochondria, fenestration of plasma membrane prior to nuclear membrane, and scattering condensation of nuclear chromatin. Cotreatment with 1.8 microg NT-4/5 augmented the striatal damage 24 h following the injections of Fe(2+). This study implies that free radicals produce necrotic degeneration in vivo as well as in vitro that becomes more sensitive in the presence of neurotrophins.

Retroviral expression of the hepatitis B virus x gene promotes liver cell susceptibility to carcinogen-induced site specific mutagenesis

Mutational inactivation of the tumor suppressor gene p53 is common in hepatocellular carcinomas (HCC). AGG to AGT transversion in codon 249 of exon 7 of the p53 gene occurs in over 50% of HCC from endemic regions, where both chronic infection with the hepatitis B virus (HBV) and exposure to carcinogens such as aflatoxin B1 (AFB1) prevail. In this study, we report the effect of the HBV x protein (HBx) on carcinogen-induced cytotoxicity and AGG to AGT mutation in codon 249 of the p53 gene in the human liver cell line CCL13. Expression of HBx, as revealed by its transactivation function, results in enhanced cell susceptibility to cytotoxicity induced by the AFB1 active metabolite, AFB1-8,9-epoxide, and benzo(a)pyrene diol-epoxide. Under similar conditions, expression of HBx promotes apoptosis in a subset of cell population. Exposure to AFB1-8, 9-epoxide alone induces a low frequency of AGG to AGT mutation in codon 249 of the p53 gene, as determined by an allele-specific polymerase chain reaction (AS-PCR) assay. However, expression of HBx enhances the frequency of AFB1-epoxide-induced AGG to AGT mutation compared to control cells. In summary, this study demonstrates that expression of HBx enhances liver cell susceptibility to carcinogen-induced mutagenesis, possibly through alteration of the balance between DNA repair and apoptosis, two cellular defense mechanisms against genotoxic stress.

Apoptosis of primary-culture rat microglial cells induced by pathogenic Acanthamoeba spp

To determine whether trophozoites and lysates of pathogenic Acanthamoeba spp. induce apoptosis in primary-culture microglial cells, transmission electron microscopic (TEM) examinations, assessment of DNA fragmentation by agarose gel electrophoresis, and the TdT-mediated dUTP nick-end labeling assay were performed. When a trophozoite of pathogenic Acanthamoeba culbertsoni came in contact with a microglial cell, the digipodium was observed by TEM. Nuclear chromatin condensation was observed in 10% of microglial cells, while it was not revealed when they were cocultured with weakly pathogenic Acanthamoeba royreba trophozoites. DNA fragmentation in microglial cells cocultured with the A. culbertsoni lysate was detected by electrophoresis, showing DNA ladder formation, whereas it was hardly observed in microglial cells cocultured with A. royreba. DNA fragmentation of microglial cells was also confirmed by flow cytometry analysis. The fluorescence of TdT-stained apoptotic bodies became intensely visible with microglial cells cocultured with the A. culbertsoni lysate. In contrast, with microglial cells cocultured with the A. royreba lysate, only a background level of fluorescence of TdT-stained apoptotic bodies was detected. These results suggest that some rat microglial cells cocultured with pathogenic A. culbertsoni undergo cytopathic changes which show the characteristics of the apoptotic process, such as nuclear condensation and DNA fragmentation.

DNA-binding activity of the N-terminal cleavage product of poly(ADP-ribose) polymerase is required for UV mediated apoptosis

The role of the N-terminal cleavage product of poly(ADP-ribose) polymerase (PARP) on UV mediated apoptosis was investigated in cultured HeLa cells. Ultrastructural analysis of cells expressing caspase-resistant PARP (PARP(D214A)) revealed the typical features of necrosis following UV treatment. However, cells co-expressing PARP(D214A) with the N-terminal fragment of PARP containing the DNA-binding domain underwent apoptosis instead of necrosis. In this study, we have demonstrated that the DNA-binding activity of the N-terminal fragment of PARP is important for the execution of apoptosis. Point mutations were introduced in the DNA-binding sites of the N-terminal fragment. Cells co-expressing PARP(D214A) with the mutated N-terminal fragments neither stimulated apoptosis nor prevented necrosis in response to UV irradiation. The present study proposes that the DNA-binding activity of the N-terminal fragment of PARP in UV treated cells prevents cellular ATP depletion, a mechanism by which necrotic cell death is triggered.

Outcome of adults with repaired tetralogy of Fallot

Outcome of adult patients with repaired tetralogy of Fallot (TOF) was studied with emphasis on postrepair problems. A retrospective review of clinical, echocardiographic, catheterization, and surgical data was performed for 48 patients who underwent corrective repair of TOF after 15 years of age. All patients survived total repair and have been followed up from 3 months to 11 years (median 4.6 years). Postoperatively, 81.3% of patients were in functional class I and 85.4% had normal right ventricular function. One patient (2.1%) died during follow-up. There were 6 reoperations (12.5%) in 5 patients. The indications for reoperation included residual ventricular septal defect (VSD) (n=1), right ventricular outflow obstruction with VSD (n=4), and pulmonary regurgitation (n=1). The 10-year actuarial survival rate was 97.1%, and the 10-year freedom from reoperation was 81.3%. Aortic regurgitation was seen preoperatively in 6 patients (12.5%) and there were 2 newly developed aortic regurgitations after operation, one of which was caused by infective endocarditis. Corrective repair of TOF can be recommended in this patient group since the survival rate, postrepair functional status and hemodynamics are acceptable. Continued close follow-up, however, is essential for early identification and correction of post-repair problems.

Characterization of MPP(+)-induced cell death in a dopaminergic neuronal cell line: role of macromolecule synthesis, cytosolic calcium, caspase, and Bcl-2-related proteins

To further characterize MPP(+)-induced cell death and to explore the role of Bcl-2-related proteins in this death paradigm, we utilized a mesencephalon-derived dopaminergic neuronal cell line (MN9D) stably transfected with human bcl-2 (MN9D/Bcl-2), its C-terminal deletion mutant (MN9D/Bcl-2Delta22), murine bax (MN9D/Bax), or a control vector (MN9D/Neo). As determined by electron microscopy and TUNEL assay, MN9D/Neo cells exposed to MPP(+) underwent a cell death that was characterized by mitochondrial swelling and irregularly scattered heterochromatin without accompanying DNA fragmentation. However, cell swelling typically seen in necrosis did not appear. To examine the biochemical events associated with MPP(+)-induced cell death, various analyses were conducted. Addition of a broad-spectrum caspase inhibitor, N-benzyloxycarbonyl-Val-Ala-Asp-fluoromethylketone (50-400 microM) or Boc-aspartyl(OMe)-fluoromethylketone (50-200 microM) did not attenuate MPP(+)-induced cell death while the same treatment protected MN9D/Neo cells against staurosporine-induced apoptotic cell death. Concurrent treatment with an inhibitor of macromolecule synthesis such as cycloheximide, emetine, or actinomycin D blocked MPP(+)-induced cell death, suggesting that new protein synthesis is required as demonstrated in many apoptotic cell death. The level of cytosolic calcium in MN9D/Neo cells was unchanged over 24 h following MPP(+) treatment, as monitored by means of the fluorescent probe Fura-2. Western blot analysis indicated that expression level of proapoptotic protein, Bax was not significantly altered after MPP(+) treatment. In this death paradigm, overexpression of Bcl-2 but not its C-terminal deletion mutant attenuated MPP(+)-induced cell death whereas overexpression of Bax had no effect. Taken together, these data indicate that (i) MPP(+) induces a distinct form of cell death which resembles both apoptosis and necrosis; and (ii) full-length Bcl-2 counters MPP(+)-induced morphological changes and cell death via a mechanism that is dependent on de novo protein synthesis but independent of cytosolic calcium changes, Bax expression, and/or activation of caspase(s) in MN9D cells.

Sequential cleavage of poly(ADP-ribose)polymerase and appearance of a small Bax-immunoreactive protein are blocked by Bcl-X(L) and caspase inhibitors during staurosporine-induced dopaminergic neuronal apoptosis

To assess the role of Bcl-X(L) and its splice derivative, Bcl-X(S), in staurosporine-induced cell death, we used a dopaminergic cell line, MN9D, transfected with bcl-xL (MN9D/Bcl-X(L)), bcl-xS (MN9D/Bcl-X(S)), or control vector (MN9D/Neo). Only 8.6% of MN9D/Neo cells survived after 24 h of 1 microM staurosporine treatment. Caspase activity was implicated because a caspase inhibitor, N-benzyloxycarbonyl-Val-Ala-Asp-fluoromethyl ketone (Z-VAD-fmk), attenuated staurosporine-induced cell death. Bcl-X(L) rescued MN9D cells from death (89.4% viable cells), whereas Bcl-X(S) had little or no effect. Bcl-X(L) prevented morphologically apoptotic changes as well as cleavage of poly(ADP-ribose)polymerase (PARP) induced by staurosporine. It is interesting that a small Bax-immunoreactive protein appeared 4-8 h after PARP cleavage in MN9D/Neo cells. The appearance of the small Bax-immunoreactive protein, however, may be cell type-specific as it was not observed in PC12 cells after staurosporine treatment. The sequential cleavage of PARP and the appearance of the small Bax-immunoreactive protein in MN9D cells were blocked either by Z-VAD-fmk or by Bcl-X(L). Thus, our present study suggests that Bcl-X(L) but not Bcl-X(S) prevents staurosporine-induced apoptosis by inhibiting the caspase activation that may be directly or indirectly responsible for the appearance of the small Bax-immunoreactive protein in some types of neurons.

Necrosis and apoptosis after retinal ischemia: involvement of NMDA-mediated excitotoxicity and p53

PURPOSE

Accumulated evidence has shown that apoptosis and necrosis contribute to neuronal death after ischemia. The present study was performed to study the temporal and spatial patterns of neuronal necrosis and apoptosis after ischemia in retina and to outline mechanisms underlying necrosis and apoptosis.

METHODS

Retinal ischemia was induced by increasing intraocular pressure to a range of 160 mm Hg to 180 mm Hg for 90 minutes in adult rats. The patterns of neuronal cell death were determined using light and electron microscopy and were visualized by TdT-dUTP nick-end labeling (TUNEL). The mRNA expression profile of p53 was examined using reverse transcription-polymerase chain reaction (RT-PCR) and in situ hybridization histochemistry. Immunohistochemistry was performed using anti-p53, anti-microtubule associated protein-2, and anti-glial fibrillary acidic protein antibodies.

RESULTS

Within 4 hours after ischemia, neurons in the inner nuclear cell layer (INL) and ganglion cell layer (GCL) underwent marked necrosis, made apparent by swelling of the cell body and mitochondria, early fenestration of the plasma membrane, and irregularly scattered condensation of nuclear chromatin. After 3 days, the INL and GCL neurons showed further degeneration through apoptosis marked by cell body shrinkage, aggregation, and condensation of nuclear chromatin. Apoptotic neurons were also observed sparsely in the outer nuclear cell layer. Intravitreal injections of MK-801 prevented early neuronal degeneration after ischemia. Of note, mRNA and protein levels of p53, the tumor suppressor gene known to induce apoptosis, were increased in the retinal areas undergoing apoptosis 1 to 3 days after ischemic injury.

CONCLUSIONS

Ischemia produces the N-methyl-D-aspartate-mediated necrosis and slowly evolving apoptosis of neurons in the retina. The latter may depend on the expression of the p53 proapoptosis gene.

Zinc-induced cortical neuronal death with features of apoptosis and necrosis: mediation by free radicals

Some studies have provided evidence that delayed death of hippocampal CA1 neurons in transient global ischemia occurs by classical apoptosis. Recently, translocation of synaptic zinc has been shown to play a key role in ischemic CA1 neuronal death. With these two lines of evidence, we examined in mouse cortical cultures the possibility that zinc neurotoxicity, slowly triggered over a day, may occur by classical apoptosis. Exposure of cortical cultures to 30-35 microM zinc for 24 h resulted in slowly evolving death of neurons only, while exposure to zinc at higher concentrations ( > or = 40 microM) produced near-complete death of both neurons and glia. DNA agarose gel electrophoresis revealed internucleosomal DNA fragmentation, and the terminal deoxynucleotidyl transferase-mediated dUTP nick end labeling method revealed DNA breaks in degenerating neurons after 24 h exposure to 30-35 microM zinc, suggesting that the death may occur by apoptosis. However, electron-microscopic examinations revealed ultrastructural changes clearly indicative of necrosis, such as marked swelling of intracellular organelles and disruption of cell membranes amid relatively intact nuclear membranes. Furthermore, the slowly triggered zinc neurotoxicity was not attenuated by cycloheximide, neurotrophins (brain-derived neurotrophic factor, neurotrophin-3, neurotrophin-4/5) or high potassium, all of which effectively reduced several forms of apoptosis in our cortical cultures. Interestingly, a vitamin E analogue trolox almost completely blocked slowly triggered zinc neurotoxicity, indicating that free radical injury is the main mechanism of zinc neurotoxicity. Consistently, exposure to zinc increased membrane lipid peroxidation assessed by the thiobarbituric acid reactive substance assay. Although zinc-induced neuronal death, slowly triggered over a day, is associated with DNA fragmentation, overall it exhibited features more typical of necrosis. This neuronal death is probably mediated by free radical injury. Further studies appear warranted to investigate the mechanistic link between toxic zinc influx and free radical generation and the possibility that selective neuronal death in transient global ischemia also occurs by zinc-triggered neuronal death exhibiting features of both apoptosis and necrosis.

Zn2+ entry produces oxidative neuronal necrosis in cortical cell cultures

Evidence has accumulated that Zn2+ plays a central role in neurodegenerative processes following brain injuries including ischaemia or epilepsy. In the present study, we examined patterns and possible mechanisms of Zn2+ neurotoxicity. Inclusion of 30-300 microM Zn2+ for 30 min caused neuronal necrosis apparent by cell body and mitochondrial swelling in cortical cell cultures. This Zn2+ neurotoxicity was not attenuated by antiapoptosis agents, inhibitors of protein synthesis or caspase. Blockade of glutamate receptors or nitric oxide synthase showed no beneficial effect against Zn2+ neurotoxicity. Interestingly, antioxidants, trolox or SKF38393, attenuated Zn(2+)-induced neuronal necrosis. Pretreatment with insulin or brain-derived neurotrophic factor increased the Zn(2+)-induced free radical injury. Kainate or AMPA facilitated Zn2+ entry and potentiated Zn2+ neurotoxicity in a way sensitive to trolox. Reactive oxygen species and lipid peroxidation were generated in the early phase of Zn2+ neurotoxicity. These findings indicate that entry and accumulation of Zn2+ result in generation of toxic free radicals and then cause necrotic neuronal degeneration under certain pathological conditions in the brain.

The use of combined heparin/aspirin and immunoglobulin G therapy in the treatment of in vitro fertilization patients with antithyroid antibodies

PROBLEM

To compare the effect of heparin/aspirin therapy alone vs. heparin/aspirin in combination with intravenous immuno-globulin (IVIg) immunotherapy on in vitro fertilization (IVF) outcome of patients who test positive for antithyroid antibodies (ATAs).

METHOD OF STUDY

Eighty-two women younger than 40 years of age whose infertility was related exclusively to female causes were evaluated. All tested positive for organ-specific antithyroid antibodies (antimicrosomal and/or antithyroglobulin antibodies), but negative for antiphospholipid antibodies. Thirty-seven of these women (group A) received H/A alone, whereas 45 (group B) received heparin/aspirin in combination with IVIg.

RESULTS

Ten (27%) of women in group A and 23 (51%) of women in group B achieved live births after completion of a single IVF/embryo transfer cycle (P = 0.027).

CONCLUSION

We conclude that IVIg therapy significantly improves IVF success rates in ATA+ women.

Glutamate neurotoxicity in mouse cortical neurons: atypical necrosis with DNA ladders and chromatin condensation

The possibility that glutamate may induce neuronal apoptosis was examined in cultured cortical neurons. Neurons underwent widespread death 24 h following exposure to 50 microM glutamate. The glutamate neurotoxicity was blocked by inclusion of the glutamate antagonists, 10 microM MK-801 and 50 microM CNQX. The death was characterized by swelling cell body and bursting cytoplasmic membrane in the early phase of degeneration, suggesting that glutamate produces receptor-mediated excitotoxic necrosis. With blockade of excitotoxicity by addition of 10 microM MK-801 and 50 microM CNQX, cortical neurons exposed to 2 mM glutamate underwent necrosis morphologically identical to excitotoxicity but sensitive to 100 microM trolox, an antioxidant, suggesting that high doses of glutamate produce oxidative neuronal necrosis via non-receptor-mediated mechanisms. Interestingly, internucleosomal DNA fragmentation and chromatin condensation were observed in the course of glutamate-induced neuronal necrosis.

Behçet's disease-like symptoms induced by the Herpes simplex virus in ICR mice

Herpes simplex virus (HSV) infection has been suggested to be one of the etiologic or triggering factors in Behçet's disease. To test this hypothesis, 258 ICR mice were inoculated with HSV type 1 (KOS strain). After the induced infection, 86 mice (33.3%) died, 77 (29. 8%) showed Behçet's disease-like symptoms, and 95 (36.8%) had a healthy, normal appearance or just a single symptom. The symptoms included skin ulcers on the earlobe, neck, abdomen, back or face (57. 1%); eye syndromes (39.0%); partial hair loss (33.8%); genital ulcers (19.5%); bullae (11.7%); arthritis (5.2%); gastrointestinal ulcer (5.2%); and tongue ulcers (3.9%). The induced Behçet's disease-like symptoms are similar to the clinical manifestations of ulcers, uveitis, and arthritis which have been significant in diagnosing Behçet's disease in patients.

Etiopathology of Behçet's disease: herpes simplex virus infection and animal model

The etiology of Behçet's disease has been proposed as being a viral, bacterial, genetic and immunological disorder. After Hulusi Behçet's viral etiological hypothesis, many investigators have tried to confirm this. Scrapings and fluids from patients were applied to subculture in chorioallantoic membranes of fertilized eggs as well as in mice and rabbits by direct intracerebral injection. Since the 1980s, in situ hybridization, blotting, and polymerase chain reaction has also been applied to identify the herpes simplex virus DNA and RNA in patients. Animal models were developed based on environmental pollutants, bacterial and human heat shock protein derived peptides and virus injection. Using these animal models separately and/or concurrently, allows for a more effective investigation into Behçet's disease.

Estrogen blocks neurotoxic effects of beta-amyloid (1-42) and induces neurite extension on B103 cells

Clinical studies have shown that estrogen replacement therapy is associated with reduced risk of Alzheimer's disease (AD). We tested whether or not estrogen blocks neurotoxic effects of beta-amyloid (1-42) (A beta1-42) on cultured B103 cells. A beta1-42 (1 microM) induced typical necrotic cell death, as revealed by light and electron microscopic examinations. Co-administration of estrogen not only blocked A beta1-42 toxicity to a large degree, but also enhanced neurite extension. Pretreatment with estrogen was even more effective in blocking A beta1-42 toxicity. When added 18 h after the beginning of A beta1-42 treatment, estrogen was still effective in halting the progress of cell death and enhancing neurite extension. The protection against A beta1-42-induced neuronal death by estrogen was unlikely due to a blockade of lipid peroxidation injury, since estrogen completely failed to attenuate ferrous chloride-induced cell death. These results demonstrate that estrogen blocks A beta1-42-induced neurotoxicity and enhances neurite extension on B103 cells, both of which may well be underlying mechanisms of beneficial effects of estrogen in AD.

Rare variants of divided right ventricle with sequestered apical trabecular component

The right ventricle may be divided into two or more compartments by various structures in various ways. Rarely, the apical trabecular component may be sequestered from the rest of the right ventricle. We report 4 cases with different underlying lesions that share a common pathology of apical sequestration of the right ventricle resulting in diverse hemodynamic consequences. Case 1 had pulmonary valve stenosis. The apical sequestration of the right ventricle resulted in no significant hemodynamic consequence. Case 2 had multiple defects in the muscular ventricular septum. The volume of left-to-right shunt seemed to be reduced because of the commitment of some of the defects to the sequestered cavity. Case 3 had a large defect in the trabecular septum. As the defect involved the whole septum that was related to the sequestered right ventricular apex, the left ventricle together with the sequestered right ventricle formed a boot-shaped chamber. Hemodynamically, the muscular shelf was an interventricular septum. Case 4 had a coronary artery fistula to an isolated cavity that occupied the apical region of the right ventricle. The pathology was similar to the case that was reported as a five-chambered heart. The abnormal cavity was, in fact, the sequestered right ventricular apex.

Central nervous system involvement in patients with scrub typhus

Scrub typhus, which is caused by Orientia tsutsugamushi, is a systemic illness that causes generalized vasculitis. The central nervous system (CNS) is the most crucial target in other rickettsial diseases; however, there have been several reports of encephalitis or meningitis without direct evidence of rickettsial invasion of the CNS in cases of scrub typhus. To investigate CNS involvement in cases of scrub typhus, we analyzed the CSF profiles (cell count and levels of protein and glucose) and amplified rickettsial DNA in CSF specimens by means of nested polymerase chain reaction (PCR) for 25 patients with the infection. Mild pleocytosis was present in 48% of the patients: CSF white blood cell counts ranged from 0 to 110/mm3 (mean [+/- SD] count, 16.3 +/- 27.0/mm3), and the mean (+/- SD) lymphocyte proportion was 51.9% +/- 23.9%. The CSF protein level was increased (>50 mg/dL) in seven patients. Nested PCR amplified six products from the 25 CSF specimens: four of the products were Boryong genotypes, and two were Karp genotypes. The results of this study suggest that O. tsutsugamushi does invade the CSF and that scrub typhus should be considered one of the causes of mononuclear meningitis in areas of endemicity.

Polymerase chain reaction reveals herpes simplex virus DNA in saliva of patients with Behçet's disease

The etiology of Behçet's disease is unclear, but viral infection is thought to be one etiologic factor. The aims of this study were to detect herpes simplex virus (HSV) DNA in the saliva of patients with Behçet's disease and of healthy persons, to determine whether the presence of HSV in saliva is associated with the presence of intraoral ulcer, and to investigate the relationship between HSV and Behçet's disease. The polymerase chain reaction (PCR) was used to detect HSV DNA sequences in DNA extracted from the saliva of patients with Behçet's disease and of healthy control subjects. Of 66 patients with Behçet's disease diagnosed clinically, 19 were diagnosed as complete type, 29 as incomplete type and 18 as suspected type. Of 66 DNA preparations from the saliva of the patients, 26 (39.4%) showed the 289-bp band. This contrasts with 12 of 87 preparations (13.8%) from healthy controls (P < 0.01). There were no significant differences among the three patient groups. All the 289-bp bands analyzed by restriction endonuclease digestion yielded the expected 158-bp and 131-bp fragments when digested with PstI.HSV DNA was detected in 12 of 33 Behçet's disease patients (36.4%) with oral ulceration and 14 of 33 patients (42.4%) without oral ulceration at the time of testing. There was no statistically significant correlation in the PCR results between the two groups.

Partial and transient relief of conduit obstruction by low-pressure balloon dilation in patients with congenital heart disease

Seven patients underwent attempted low pressure balloon dilation of stenotic conduits or homografts from right ventricle to pulmonary artery (n = 5), in the aortic valve position (n = 1), or from right atrium to left pulmonary artery (n = 1). In the right ventricle to pulmonary artery group, mean gradient reduction was only 17%. At follow-up, two patients underwent surgical conduit replacement, one had a stent implanted at cardiac catheterization, the other two are awaiting surgical intervention. The patient with a homograft in the aortic valve position had a good initial result but restenosed within 1 year and underwent a pulmonary autograft operation. The patient with the Fontan homograft stenosis had transient obstruction relief but subsequently required stent implantation. Low-pressure balloon dilation of conduits or homografts is only partially and transiently successful. Whether stent implantation will offer better long-term results remains to be determined.

Acute and follow-up intravascular ultrasound findings after balloon dilation of coarctation of the aorta

BACKGROUND

The study objective was to examine the vascular wall changes caused by balloon dilation of coarctation of the aorta (CoA) acutely and at short-term follow-up using intravascular ultrasound imaging. Intravascular ultrasound has been valuable in assessing the vessel wall changes in coronary and peripheral arteries after balloon dilation, often with more detail than angiography.

METHODS AND RESULTS

Intravascular ultrasound imaging, using 4.8F, 20-MHz or 6.2F, 12.5-MHz catheters on either Diasonics or HP scanners, was performed in 17 patients during balloon angioplasty for native (n = 12) and recurrent (n = 5) CoAs. Nine patients were also studied at the time of follow-up cardiac catheterization 28.1 +/- 18.0 months after angioplasty. Immediately after dilation, the mean pressure gradient across the CoA decreased from 42.9 +/- 16.4 to 9.0 +/- 5.4 mm Hg (P < .001) and the mean diameter of the coarcted segment increased from 4.4 +/- 1.9 to 7.9 +/- 2.4 mm (P < .001). An intimal tear or flap was noted by ultrasound in 12 of the 12 native CoAs and 4 of the 5 recoarctations. In contrast, only 6 of the native CoAs and 2 of the recoarctations had an intimal flap or dissection detected by angiography. At follow-up, the residual pressure gradient did not significantly change from that measured immediately after dilation, but the CoA diameter increased from 7.8 +/- 1.5 to 9.9 +/- 2.3 mm (P < .01). No aneurysms were detected. Four of the 9 patients showed ultrasonic and angiographic evidence of healing and remodeling with diminution in size or disappearance of the intimal tears.

CONCLUSIONS

There is a high incidence of intimal tears and dissections immediately after balloon angioplasty for native and recurrent CoAs. Intravascular ultrasound is more sensitive than angiography in detecting the vascular wall changes. Even significant intimal tears are not necessarily associated with aneurysm formation, and many decrease in size or disappear at short-term follow-up.