[Tau protein in cerebrospinal fluid--a potential marker of Alzheimer's disease]

Levels of the microtubule-associated protein tau in cerebrospinal fluid (CSF-tau) were measured in samples from 87 patients with Alzheimer's disease (AD), 114 patients with non-AD neurological diseases, and 22 normal control subjects, by sandwich enzyme-linked immunosorbent assay. The CSF-tau level was significantly higher in patients with AD than in patients with non-AD neurological diseases and in controls. High CSF-tau levels were found irrespective of age at onset, apolipoprotein E genotype, clinical stage, and ethnic group. Western blots of AD CSF proteins revealed two to three immunoreactive bands with apparent molecular mass between 50 and 65 kDa, which is consistent with phosphorylated CSF-tau. These results suggest that CSF-tau reflects progressive accumulation of tau due to the progressive death of neurons in the AD brain. Assay of CSF-tau may prove to be a reliable diagnostic test for AD.

Coexpression of cell-surface immunoglobulin (sIg), terminal deoxynucleotidyl transferase (TdT) and recombination activating gene 1 (RAG-1): two cases and derived cell lines

While it is generally agreed that in the lymphoid differentiation of B lineage cells there is no stage in which cell-surface immunoglobulin (sIg) and terminal deoxynucleotidyl transferase (TdT) are expressed simultaneously, a few B cell acute lymphoblastic leukemia (B-ALL) cases with this phenotype have been reported. Two such cases and the derived cell lines are reported here, in which the expression of recombination activating gene-1 (RAG-1) was also detected. One case was a CD19+ CD22+ HLA-DR+ sIg+ (gamma, kappa) B-ALL. The cell line (Bay9I) also expressed CD10. Karyotypic analysis revealed t(14;18)(q32;q21) and additional aberrations. In the other case, the fresh leukemia cells expressed CD19, CD24 and HLA-DR antigen. The derived cell line (Tree92) also expressed CD22 and sIg (mu, lambda). The karyotype of the Tree92 cells was t(8;14)(q24;q32) with additional aberrations. Tree92 is the first established cell line having both t(8;14)(q24;q32) and TdT. TdT was detected by Northern blotting as well as indirect immunofluorescence analysis. In addition, both Bay9I and Tree92 expressed RAG-1, as detected by Northern blot analysis. Cross-linking of sIg on Tree92 cells with anti-mu antibody led to significant down-regulation of RAG-1 expression. It seems that there is a sIg+ TdT+ RAG-1+ B lineage differentiation stage, and that signaling through sIg can modulate RAG-1 expression.

Antinociceptive effects of epidural and intravenous ketamine to somatic and visceral stimuli in rats

PURPOSE

To evaluate the antinociceptive effect of epidural and intravenous ketamine on somatic and visceral stimuli and to address the emergency reaction.

METHODS

Rats were randomly allocated into nine groups (n = 6); five groups with chronically implanted epidural catheters received saline or 0.5, 1, 2 and 4 mg. kg-1 ketamine epidurally, four groups received saline, or 1, 5 and 10 mg. kg-1 ketamine i.v. To assess somatic and visceral antinociceptive effects, tail flick (TF) test and colorectal distension (CD) test were carried out, respectively. Emergence reactions were graded. Maximal possible effects (% MPE) were calculated.

RESULTS

Epidural ketamine increased % MPE in both tests in a dose-dependent fashion for 30 min (vs saline group, P < 0.05). Epidural ketamine 0.5 mg. kg-1 produced an increase in % MPE in the CD test (P < 0.05) but failed in the TF test. Intravenous ketamine, 10 mg. kg-1, produced 100 +/- 0 (mean +/- SE) % MPE in the CD test but 36 +/- 15% MPE in the TF test. Dose response curves indicated greater visceral antinociception than somatic. All rats showed emergence reactions following intravenous ketamine 10 and 5 mg. kg-1.

CONCLUSION

Both epidural and intravenous ketamine produce greater antinociceptive effects to visceral than to somatic stimulation, and that epidural ketamine has a low incidence of emergence reactions.

Fulminant hepatic failure caused by ecarazine hydrochloride (a hydralazine derivative)

The cause of fulminant hepatic failure is reported to be unknown in more than half the cases in Japan. We recently reviewed 23 cases of fulminant hepatic failure that had been treated at our hospital. The cause of disease had been regarded as unknown before this study. It was found that seven of these patients had been under ecarazine hydrochloride therapy when they developed fulminant hepatic failure. We examined the reasons why fulminant hepatic failure in these seven patients had not been previously attributed to ecarazine, and found that it could be explained by the following factors: (1) the time from the start of ecarazine therapy to the onset of hepatic failure was long; (2) in all cases, hepatic failure developed more than 10 days after the clinical recognition of hepatitis; and (3) characteristic signs of drug-induced hepatic failure such as a skin rash and positive lymphocytes stimulation test with the drug were absent in all cases. Fulminant hepatic failure in these cases could be characterized by: (1) rapid decrease in serum alanine transaminase (ALT) level after discontinuation of ecarazine, (2) prolonged jaundice despite discontinuation of ecarazine, (3) high incidence of anti-nuclear antibody (ANA) (57%), and (4) histological findings of extensive hepatocellular necrosis ranging from bridging necrosis to massive necrosis. Of the seven patients, four died of fulminant hepatic failure. These four patients had received high doses of ecarazine hydrochloride for prolonged periods. Our data suggest that there may be many cases in which the cause of fulminant hepatic failure or acute hepatitis was not previously determined that can be attributed to long-term drug therapy for chronic diseases.

Herbal medicine 'Sho-saiko-to' induces tumour necrosis factor-alpha and granulocyte colony-stimulating factor in vitro in peripheral blood mononuclear cells of patients with hepatocellular carcinoma

'Sho-saiko-to' (TJ-9) is a Japanese herbal medicine that is commonly administered to patients with chronic viral liver disease in order to improve their overall physical condition and to prevent the development of liver cancer, The present in vitro study demonstrated that, by adding TJ-9 to cell cultures, there were dose-dependent increases in production levels of tumour necrosis factor-alpha (TNF-alpha) and granulocyte colony-stimulating factor (G-CSF) in peripheral mononuclear cells of patients with hepatocellular carcinoma accompanied by liver cirrhosis. Increases in the production of TNF-alpha and G-CSF in control cell cultures exposed to different herbal medicines were low, and this indicates the specificity of the response increases in production of these cytokines to TJ-9. TNF-alpha and G-CSF are known to play important roles in the biological defence mechanism. Administration of TJ-9 may, therefore, be beneficial for patients afflicted with intractable liver diseases because it could mildly induce these cytokines.

Long-term administration of natural interferon-alpha in patients with chronic hepatitis C: relationship to serum RNA concentration, HCV-RNA genotypes, histological changes and hepatitis C virus

To virologically assess the efficacy of interferon therapy in chronic hepatitis C, either 5 or 10 MU/day natural interferon-alpha (IFN alpha) was administered to 57 patients with chronic hepatitis C for 38 weeks. A complete and sustained response (CR-SR), as evidenced by the absence of serum hepatitis C virus (HCV)-RNA during the administration period and at 6 months after the final administration of IFN alpha and normal GPT level at 6 months after final administration, occurred in 42.6% (23/54) of subjects. Liver tissue was histologically evaluated using the histological activity index (HAI) score before and after the administration period. In CR-SR cases, significant improvements (P < 0.01) occurred in periportal necrosis, intralobular necrosis, portal inflammation and total score. A comparison, by HCV genotypes, revealed that CR-SR occurred in 60% (9/15) of subjects with type 2a and 30.3% (10/33) of subjects with type 1b. A comparison by virus concentration revealed that CR-SR occurred in 71.4% (15/21) of those subjects having a virus concentration of < 10(5) copies/mL, but in only 24.2% (8/33) of those having a virus concentration of > 10(5) copies/mL. Analysis by a multiple logistic model revealed a strong correlation between the therapeutic effect of interferon therapy and the pre-administration virus concentration (P = 0.0061) and genotype (P = 0.0015). These results suggest that the pre-administration virus concentration and genotype are both key factors affecting the therapeutic effect of interferon therapy in chronic hepatitis C and that the therapeutic effect of interferon is satisfactorily high, irrespective of virus concentration, in subjects with type 2a HCV, but varies depending on virus concentration in subjects with type 1b.

The effects of epidural anesthesia on ventilatory response to hypercapnia and hypoxia in elderly patients

Epidural anesthesia may impair pulmonary ventilation in elderly people. We examined the effects of lumbar or thoracic epidural anesthesia on resting ventilation, arterial blood gas tensions, the ventilatory response to hypercapnia, and progressive isocapnic hypoxia in elderly patients. Two groups of eight unpremedicated elderly patients, aged 65 yr or older, undergoing lower or upper abdominal surgery, respectively, were studied twice before and 20 min after the lumbar or thoracic administration of 10 mL of 2% lidocaine. Lumbar epidural anesthesia had no significant effect on resting ventilation, whereas thoracic epidural caused a significant 13% decrease in minute ventilation and a 14% decrease in tidal volume (P < 0.05). The ventilatory response to hypercapnia was significantly increased after lumbar epidural anesthesia, but no change was observed after thoracic epidural anesthesia. The slope of the hypoxic response curve did not show any change in either group, but minute ventilation at a Spo2 of 90% significantly increased after lumbar epidural anesthesia (P < 0.05). We conclude that neither lumbar nor thoracic epidural anesthesia per se impairs the ventilatory response to hypercapnia and hypoxia, despite slight impairment in resting ventilation by thoracic epidural anesthesia, in elderly patients.

Intrathecal prostaglandin E1 produces a long-lasting allodynic state

The existence of prostaglandin (PG) receptors in the spinal cord has been demonstrated, but their role in sensory processing is not yet well defined. PGE1 is widely used clinically as a vasodilator. The present study was designed to investigate the effects of intrathecally administered PGE1 on the transmission of different types to sensory information, including that associated with noxious somatic, noxious visceral, and non-noxious somatic stimulation. The tail-flick (TF) test was employed to measure responses to noxious somatic stimuli, and the colorectal distension test was used to examine responses to noxious visceral stimuli. Withdrawal response to mechanical pressure produced by Semmes-Weinstein mono-filaments (SWMs) was measured as an assessment of sensitivity to non-noxious mechanical somatic stimulation. TF latencies and colorectal distension thresholds decreased for a short time (10-20 min) following the intrathecal (i.t.) administration of both 100 ng or 500 ng of PGE1. In sharp contrast to these short duration effects, there was a long-lasting increase in agitation scores (allodynia) produced by 3 different intensities of SWMs (0.217, 0.745 and 2.35 g) after administration of PGE1. The changes in agitation scores to SWMs were dependent on the dose of PGE1 and the intensity of stimulation. This increase of agitation score was seen when PGE1 was administered through the i.t. catheter or by direct i.t. puncture and the increase lasted for at least 2 days after drug administration. Intrathecal administration of saline, however, did not produce any changes in TF latencies, colorectal distension thresholds, or agitation scores produced by SWMs. No significant histological difference was seen between spinal cords exposed to 500 ng PGE1 and saline 48 h after drug administration. These results demonstrate that PGE1 may trigger a hypersensitive (allodynic and/or hyperalgesic) state in sensory processing pathways at the spinal level. They also indicate that long-lasting changes in processing of non-noxious, but not noxious, information produced by PGE1 continues after the disappearance of the direct action of PGE1.

Anaesthetic management for caesarean section in a patient with Kawasaki disease

Kawasaki disease (KD) or mucocutaneous lymph node syndrome is an acute febrile illness affecting mainly children under four years of age. The most important clinical feature of this disease is coronary arteritis associated with aneurysms and thrombotic occlusions, which may lead to ischaemic heart disease or sudden death. It has now been more than 20 yr since its first description, and a number of survivors of childhood KD have reached child-bearing age. Despite the possible fatal outcome of this disease in adult patients with coronary artery manifestations, no information is available regarding the obstetrical anaesthetic management of patients with a history of KD. The purpose of this report is to describe the successful use of epidural anaesthesia in a patient with a history of KD undergoing Caesarean section and to discuss the anaesthetic considerations that should be given to adult survivors of childhood KD.

[Serum cardiac troponin-T in coronary artery bypass graft and mitral valve replacement]

Serum cardiac troponin-T was measured to evaluate perioperative myocardial injury in heart surgery. Twelve patients of coronary artery bypass graft (CABG) and nine of mitral valve replacement (MVR) were selected and the measurements were performed at 3 points-before, as well as after the surgery and on the first postoperative day. Elevated serum levels of troponin-T were observed in postoperative measurement in both groups (CABG 2.98 +/- 1.44, MVR 2.57 +/- 0.52 ng.ml-1), where all the preoperative values were less than 0.1 ng.ml-1. On the first postoperative day, CABG group showed a higher serum level of troponin-T than MVR group (6.05 +/- 4.16 vs. 2.57 +/- 2.12 ng.ml-1, P < 0.05 respectively). Taking another myocardial marker, such as CK-MB or myosin light chain I, into consideration, these data indicate that myocardial injury occurs during heart surgery and the grade of injury is severer in CABG than in MVR.

Interaction of extradural morphine and lignocaine on ventilatory response

We have evaluated the effects of lumbar extradural morphine and lignocaine on the ventilatory response to carbon dioxide. Twenty-four female patients were allocated randomly to receive extradural morphine 2 mg (group M), 2% lignocaine 10 ml (group L) or a combination of morphine 2 mg and 2% lignocaine 10 ml (group ML). On the day before surgery, resting ventilatory values including minute volume (VE) and tidal volume (VT), and ventilatory response to progressive hyperoxic hypercapnia (VE/PE'CO2) were measured. On the day of surgery, the same measurements were repeated 30 min after extradural injection. Ventilatory values at rest were not altered after extradural injection. Mean VE/PE'CO2 decreased significantly after extradural morphine (P = 0.002) and increased (P = 0.011) after extradural lignocaine. Mean VE 7.3 (VE at PE'CO2 7.3 kPa) decreased significantly after extradural morphine (P < 0.001) and increased after extradural lignocaine (P = 0.047). Extradural morphine and lignocaine did not significantly alter mean VE/PE'CO2 and mean VE 7.3: 14.6 (95% confidence intervals 12.1-17.1) to 15.3 (13.1-17.6) litre min-1 kPa-1 and 22.8 (18.1-27.5) to 22.8 (17.3-28.3) litre min-1, respectively. We conclude that extradural co-administration of morphine and lignocaine did not increase the risk of respiratory depression associated with morphine.

[A new protein titrator tape for self-assessment by outpatients with proteinuria]

ł- have invented a new dipstick (protein titrator tape) for measuring the volume of protein excreted in the 24-hour urine. The principle of the method is based on the protein error of indicators with the modification of a conventional dipstick test. The dipstick consists of two thick filter papers, containing differently adjusted pH indicators of tetrabromphenol blue, making it possible to detect a wide range of protein concentrations in the urine using a standard color chart that includes twenty color blocks. Two hundred and ninety outpatients had their urine samples assessed with this method as well as with the pyrogallol red test as a comparative study for quantitative measurement of protein concentrations. The new-type dipstick method exhibited good correlation with the results of the pyrogallol red test, especially in the range of protein concentrations from 50 mg/dl to 400 mg/dl, showing the linear equation of "y (Pyrogallol red) = 10.5 + 0.99 x (Dipstick) (r = 0.91, P < 0.01)". Although there was good correlation with the pyrogallol red test at higher concentrations from 400 mg/dl to 1,000 mg/dl, the dipstick method tended to exhibit lower concentrations than those indicated by the counterpart method. The rate of consistency between observers was quite high. This new-type dipstick method will offer a reliable method for patients or their family to assess their protein excretion in the urine every 24 hours at home using a portable urine sampling device.

A clinical study of lectin-reactive alpha-fetoprotein as an early indicator of hepatocellular carcinoma in the follow-up of cirrhotic patients

Levels of two types of lectin-reactive alpha-fetoprotein (AFP), designated AFP-L3 and AFP-P4+P5, were analyzed with Lens culinaris agglutinin A and AFP-P4+P5 with erythroagglutinating phytohemagglutinin, respectively, in an attempt to determine the utility and significance of these macromolecules as early indicators of hepatocellular carcinoma during the periodic follow-up of cirrhotic patients. The subjects were 51 of 190 consecutive cirrhotic patients in whom hepatocellular carcinoma developed during a 6-year follow-up period and 21 cirrhotic patients without hepatocellular carcinoma. Serum AFP levels were of limited value to diagnose and predict hepatocellular carcinoma. The relative levels of AFP-L3 and AFP-P4+P5 in patients with hepatocellular carcinoma at the time of tumor detection were significantly higher than those in patients with cirrhosis. The sensitivity was 61%, and the specificity was 90%. Fourteen patients (48%) of 29 patients with small hepatocellular carcinomas less than 2 cm in diameter showed elevated percentage of lectin-reactive AFP. Retrospective examination of 21 patients who were positive for lectin-reactive AFP at diagnosis of hepatocellular carcinoma showed that 41% of them had already expressed lectin-reactive AFP 12 months before the direct detection of hepatocellular carcinoma by diagnostic imaging. These results lead us to conclude that the level of lectin-reactive AFP is a suitable predictive marker for the early recognition of hepatocellular carcinoma in the follow-up of patients with cirrhosis, and that measurements of the level of lectin-reactive AFP should be added to the screening methods that are now in use.

Hepatocyte regeneration in chronic hepatitis C and interferon treatment: analysis of immunohistological identification of proliferating cell nuclear antigen (PCNA)

To evaluate the usefulness of proliferating cell nuclear antigen (PCNA) immunostaining in the assessment of the efficacy of interferon (IFN) therapy in chronic hepatitis C, we investigated the proliferative activity of hepatocytes in 67 patients with chronic hepatitis C, using this immunostaining method. The percentage of PCNA-positive hepatocytes was 2.4% in patients with chronic persistent hepatitis, 2.5% in those with chronic aggressive hepatitis 2A, and 3.9% in those with chronic aggressive hepatitis 2B. The PCNA count increased with the progression of the liver disease. Patients were classified as complete, partial, and non-responders to IFN; the percentage of PCNA-positive hepatocytes before IFN therapy was 1.6% in the complete responders, 3.9% in the partial responders, and 4.9% in the non-responders. There was a significant negative correlation between the percentage of PCNA-positive hepatocytes and the response to IFN treatment. Thirty-two of 53 cases (60.4%) in which the PCNA labeling index (LI) was less than 5.0 were complete responders compared with 13 of 14 cases (92.9%) in which the PCNA LI was higher than 5.0, representing partial responders or non-responders (P < 0.001). Most complete responders had a low PCNA LI, irrespective of HCV genotype. Our findings indicate that PCNA immunostaining is a simple and reliable index of cell proliferation in liver regeneration, and may be a useful predictor of the response to IFN treatment in chronic hepatitis C.

[Acute pancreatitis associated with acute intermittent porphyria]

Pancreatic involvement associated with acute intermittent porphyria is rare. There were only nine cases reported until now which have pancreatic disease and AIP, one case with chronic pancreatitis, one with cystadenocarcinoma and chronic pancreatitis, one with transient macroamylasemia and the others with acute pancreatitis. The cause of these complications in these patients is uncertain. However, in our case, it is possible that AIP might have caused the acute pancreatitis, since this patient developed acute pancreatitis following the attack of AIP. It seems to be necessary to pay attention to the combination of these diseases.

[Epidural anesthesia with high dose fentanyl for a patient with dilated cardiomyopathy]

Dilated cardiomyopathy is defined as a syndrome of dilated ventricles with gross impairment of ventricular systolic function. Recently, there are several anesthetic reports regarding this syndrome. But any appropriate anesthetic method has not been established. A 59-year-old man with dilated cardiomyopathy underwent low anterior resection of rectum. We employed the technique of high dose epidural fentanyl anesthesia as the anesthetic method. During surgery, mild hypotension developed, but other cardiovascular abnormalities were not observed during and after the operation. Based on this result, the authors recommend that high dose epidural fentanyl anesthesia is an anesthetic method of choice for patients with dilated cardiomyopathy.

[Clinical significance of determination of anti-HCV antibodies]

This study was conducted to evaluate the clinical significance of assays of hepatitis C virus (HCV) antibodies to manage the liver diseases due to HCV. To detect HCV infection accurately, the second-generation anti-HCV assays such as EIA, PHA and TND-2 were more useful than other assays such as anti-C100-3 antibody, anti-GOR antibody, and anti-JCC-2 antibody, because the second generation anti-HCV assays showed positive rates in over 90% of the cases with positive HCV-RNA. Although in some patients the determination of anti-GOR, anti-JCC-2, IgM anti-HCV and their titrations revealed the severity of liver disease and were useful to predict the effects of interferon therapy, measurements of these antibodies were not considered so useful as clinical parameters for management of patients with liver disease due to HCV. However, the fact that the changes of serum titer of anti-JCC-2 correlated well to the changes of serum transaminase levels in a few patients with IFN suggests that the clinical significance of anti-HCV core antibodies should be further discussed.

[The difficulties in communication through RS-232C interface between monitor devices and a personal computer--the difference of data output format and transmit mode]

We investigated data output format and transmit mode of communication through RS-232C interface between monitor devices and a personal computer. The baud rate, start bit, data bits, parity bit and stop bits are listed with transmit mode of six companies' monitor devices which are now widely sold in Japan. Each monitor device has its own data output format and transmit mode, which are quite different from the others and make it somewhat difficult to import data from different monitor devices to a personal computer. We suggest that, because two or three different monitor devices are commonly used during anesthesia, some general standard should be established to make an easy communication between monitor devices and a personal computer for ordinary users.