Impairment of the TSH signal transduction system in human thyroid carcinoma cells

In order to further evaluate the role of TSH in the proliferation and the differentiation of human thyroid carcinoma cells, we have analyzed the function of the TSH receptor in the established thyroid carcinoma cell lines NPA and WRO. The TSH signal transduction system in the carcinoma cells was also compared with that in normal thyroid cells. Although unresponsiveness to bovine and human TSH was demonstrated by measurement of cAMP production and [3H]thymidine incorporation after treatment of TSH, cAMP production was induced after stimulation of these cells by forskolin, cholera toxin, and isoproterenol. Specific binding to 125I-TSH was demonstrated in both NPA and WRO cells in addition to the existence of a TSH receptor mRNA and thyroglobulin mRNA species, although thyroid-specific gene expression in these cells was not regulated by TSH. These findings suggest that the unresponsiveness to TSH in these cells may be due to an abnormality of TSH receptor-G protein coupling rather than to a decreased level of TSH-receptor expression or a Gs protein abnormality.

Molecular cloning and sequencing of an alternatively spliced form of the human thyrotropin receptor transcript

In the present study, we report the molecular cloning and sequencing of an alternatively spliced form of the human thyrotropin receptor (hTSHR) mRNA transcript, which has previously been detected on Northern blot analysis of human thyroid cells. The smaller hTSHR cDNA, designated hTSHR cDNA-I, is approximately 1 kb in size and encodes a protein of 253 amino acids. Comparison of the nucleotide sequence of hTSHR cDNA-I with available hTSHR genomic sequence data reveals that the cDNA-I contains exons 1-8 and unidentified DNA tract, presumably an intron. Thus, the hTSHR cDNA-I encodes for the N-terminal half of the extracellular domain of the hTSHR (approximately 60%). The truncated TSHR-I may be secreted and function as a TSH binding protein.

Interleukin-1 inhibits human thyroid carcinoma cell growth

In order to further clarify the growth regulating effect of cytokines on thyroid cell proliferation, the effect of interleukin-1 (IL-1) was tested on growth of human papillary and follicular thyroid carcinoma cells (NPA and WRO). Although fetal bovine serum stimulated DNA synthesis, TSH did not affect cell growth and the level of thyroglobulin messenger RNA (mRNA) in NPA. Eight-bromo-cAMP and forskolin, however, significantly suppressed DNA synthesis, suggesting the impairment of TSH receptor signal transduction in NPA cells despite of the presence of [125I]TSH binding. Both IL-1 alpha and beta inhibited [3H] thymidine uptake into NPA cell DNA in a dose- and time-dependent manner at concentrations ranging from 5 x 10(2) to 10(5) U/L; 10(5) U/L of IL-1 suppressed DNA synthesis by more than 40% of control. The suppressive activity of IL-1 beta was more potent than that of IL-1 alpha in spite of the same lymphocytes activating factor (LAF) activity. Steady state levels of c-myc mRNA transcripts were also inhibited by both IL-1 alpha and beta, respectively. On the other hand, IL-1 alpha and beta did not affect the WRO cell growth. Although forskolin stimulated cAMP production in NPA cells, IL-1 did not induce cAMP generation. Indomethacin (1.0 approximately 10 mg/L) did not alter the suppressive activity of IL-1. Neither IL-1 alpha and beta caused a cytotoxic effect on the NPA cells. Although changes in c-myc mRNA content may just be an epiphenomenon of the decrease in proliferative activity in response to IL-1, and not a direct target of action of the peptide, these results demonstrate the inhibitory effect of IL-1 on cell growth of NPA. IL-1 may have an aspect of antitumorigenic action in some human thyroid carcinoma differentiation and replication.

[A case of medically treated type A acute aortic dissection: trial of antifibrinolytic therapy while monitoring the thrombotic and fibrinolytic parameters]

A 56-year-old male was admitted with severe chest and abdominal pain. Enhanced CT revealed type-A acute aortic dissection. Enhancement of false lumen was complete in the aortic arch, but it was incomplete in the ascending and descending aorta. This finding suggested a thrombosing tendency of the false lumen. Marked elevation of Thrombin-Antithrombin III complex (TAT) and Plasmin-alpha 2 Plasmin inhibitor complex (PIC) indicated the activation of both coagulation and fibrinolysis in the false lumen. Aprotinin and Tranexamic acid were used in order to suppress the fibrinolysis. Both TAT and PIC were completely normalized at the 20th hospital day. Enhanced CT on the 40th hospital day showed that the false lumen had disappeared, and the adventitia had thickened. Care should be taken to notice activated coagulation and fibrinolysis in the false lumen. This report appears to be the first statement about the effectiveness of antifibrinolytic therapy to facilitate thrombosing and healing of the false lumen in the treatment of acute aortic dissection.

[A successful surgical case of thoracoabdominal aortic aneurysm ruptured into the right pleural cavity]

A 55-year-old man was transferred to our cardiovascular center because of right hemothorax and hemorrhagic shock. Emergency CT scan revealed a thoracoabdominal aortic aneurysm (Crawford's type I-A) ruptured into the right thorax. The aneurysm was exposed by Stoney's spiral opening approach. A 24 mm Cooley Dacron graft was implanted in end-to-end fashion between the descending thoracic aorta and the abdominal aorta just above the celiac artery. The use of aortic artery cannula, femoral artery cannula and flexible polyvinyl tube provided safe and simple means as a temporary bypass during this graft replacement. Postoperative course was uneventful.

Multiple endocrine neoplasia type 2 with malignant pheochromocytoma — Long term follow-up of a case by131I-meta-iodobenzylguanidine scintigraphy—

The case of a 33-year-old Japanese man, who has Multiple Endocrine Neoplasia Type 2 (MEN IIa) (Sipple's syndrome) with malignant pheochromocytoma, is reported. He had survived for twelve years since the initial diagnosis of malignant pheochromocytoma. Within this period, he had undergone 131I-meta-iodobenzylguanidine scintigraphy twice, in 1983 and 1990. This is the first case in Japan of a longterm surviving patient with malignant pheochromocytoma followed up by 131I-MIBG scintigraphy. Although he had no exacerbation of clinical symptoms or urinary catecholamine levels, second scintigraphy clearly showed an increase in the tumor size, new metastasis of the malignant pheochromocytoma and exacerbation of the medullary thyroid carcinoma. Compared with any other roentgenological device and hormonal data, 131I-MIBG scintigraphy was seen to be a good tool for evaluating the localization and the progression of tumors. 131I-MIBG scintigraphy is a useful procedure not only for initial diagnosis but also for judging progression in a case of advanced malignant pheochromocytoma.

Acute adrenal insufficiency due to symptomatic Rathke's cleft cyst

A 65-year-old Japanese man who suffered from secondary hypopituitarism due to Rathke's cleft cyst is reported. Although computed tomography failed to detect any pituitary abnormality, magnetic resonance imaging demonstrated the presence of a cystic intrasellar mass, initially suggesting craniopharyngioma or abscess. Operative findings revealed Rathke's cleft cysts within the pituitary fossa which resulted in secondary hypopituitarism. Among cases of secondary hypopituitarism with abnormal findings in the pituitary, symptomatic Rathke's cleft cysts should be included in the differential diagnosis of adrenal insufficiency.

Growth hormone deficiency and empty sella syndrome in a boy with dup(X) (q13.3----q21.2)

A 2 8/12-year-old boy with severe growth failure and mental retardation was found to have a maternally derived tandem duplication of the long arm of X chromosome, dup(X) (q13.3----q21.2). Karyotypic interpretation was further confirmed in this patient by a double gene dose for red blood cell phosphoglycerate kinase. DNA replication study showed that the duplicated X chromosome was always late replicating in peripheral blood lymphocytes as well as in skin fibroblasts from the mother. Endocrine studies in the patient demonstrated growth hormone deficiency. Magnetic resonance imaging of the head then disclosed the empty sella syndrome. This appears to be the first report of a dup(Xq) patient associated with a growth hormone deficiency and the empty sella syndrome. We emphasize that duplication of the proximal Xq in males represents another microduplication syndrome (Thode-Leonard syndrome).

Unique karyotypes in two patients with Prader-Willi syndrome

A physical disruption of the Prader-Willi syndrome (PWS) chromosome region is thought to cause PWS. We describe 2 girls with PWS phenotype, who had unique chromosome 15 abnormalities. The first patient showed mosaicism: 45,XX,t(15;15)(qter----p11.1::q11.200----qter)/46,XX,t(15;15)(qter----p1 1.1::q 11.200----qter), +mar. The band 15q11.2 apparently remained intact in the t(15;15) chromosome, and the mar chromosome was considered as r(15) (p11.1q11.1). The second patient had a karyotype of 47,XX,del(15)(q11.200----q11.207), +idic (15)(pter----q11.1::q11.1----pter). The complex breakage and reunion involving the 15q11.2 regions of the father's homologous chromosomes 15 at meiosis appeared to have resulted in the idic(15) and the del(15) chromosomes. These cytogenetic findings suggest that the PWS chromosome region may be localized on the very proximal portion of band 15q11.2.

Lack of PTC gene (ret proto-oncogene rearrangement) in human thyroid tumors

PTC gene, which is derived from the rearranged form of the ret proto-oncogene, was originally discovered in human thyroid papillary carcinomas. This gene has been thought to act as a tumorigenetic factor in thyroid carcinoma, although the action of PTC oncogene products is still unknown. To study the frequency of the PTC gene present in human thyroid carcinomas, we investigated four cell lines derived from thyroid carcinoma and 22 thyroid tumor tissue specimens. The reverse transcriptase-polymerase chain reaction (RT-PCR) method was performed to detect putative PTC mRNA. The presence of the PTC gene in genomic DNA was analyzed by Southern blot hybridization. PTC mRNA was detected by the RT-PCR method in only one papillary carcinoma cell line (TPC-1 cell). Southern gel analysis confirmed the rearrangement of the ret proto-oncogene in this cell line. In the other three cell lines and 22 tumor tissue specimens, however, neither the PTC gene or mRNA was detected. These results demonstrate that the prevalence of the PTC gene in thyroid tumor is low and may not be essential for human thyroid tumorigenesis. That our present results conflict with previous reports may be due to general differences in genetic background among races.

[Blood flow measurement of brain tumor by 123I-IMP using 3-heads rotating gamma camera SPECT]

Using 3-heads rotating gamma camera SPECT system, regional blood flow was measured from the super-early image obtained 4 to 6 minutes after the intravenous injection of 123I-IMP on 11 patients with various brain tumors. Two cases of olfactory groove meningioma and malignant astrocytoma showed significantly high 123I-IMP uptake by the lesion visualized by MRI compared to the uptake by normal brain cortex on super-early image but 123I-IMP uptake by the tumor decreased on early image. In both cases, blood flow of the tumor measured from super-early image showed values much higher than those of normal brain cortex. It was thought that usual correction method based on early image did not correctly represent the blood flow of the lesion but that the present method based on super-early image could show the increase of blood flow of the tumor.

Lesion of the nucleus basalis magnocellularis does not affect cerebral cortical blood flow in rats

The effects of a unilateral ibotenic acid lesion of the nucleus basalis magnocellularis (NBM) on blood flow of the cerebral cortex and striatum were studied at 2, 4, 8 and 16 weeks after the lesion in conscious rats. In the cerebral cortex, no side-to-side difference in blood flow was observed, though cholinergic enzyme activity was markedly reduced on the side of the lesion. The results suggest that NBM lesion produces disturbance of cholinergic neurons in the cerebral cortex without significant alteration of blood flow.

Specification of small distal 6q deletions in two patients by gene dosage and in situ hybridization study of plasminogen and alpha-L-fucosidase 2

Gene-dosage and in situ hybridization study of plasminogen (PLG) and alpha-L-fucosidase 2 (FUCA2) was performed on two patients with a small deletion of the distal long arm of chromosome 6, to define the structural abnormality more precisely. The results led to the cytogenetic diagnosis of an interstitial 6q deletion, del(6)(q25.1q25.3), in one patient and of a terminal 6q deletion resulting from a paternal t(1;6)(q44;q2605) translocation in the other patient. The latter patient had congenital noncommunicating hydrocephalus due to obstruction at the level of the foramen of Monro or the third ventricle which has not previously been described in terminal 6q deletions. Review of the literature suggests the emergence of a clinical syndrome associated with terminal 6q deletions.

[Physiologically active compounds in the extracts from tochukaso and cultured mycelia of Cordyceps and Isaria]

Tochukaso is a Chinese traditional medicine composed of a fruit body of Cordyceps sinensis and its parasitic host larva. Tochukaso (C. sinensis) and the cultured mycelia of five species of Cordyceps and four species of Isaria were each extracted with hot water and examined for the inotropic effect on guinea-pig right atrium in vitro system. The extracts from C. militaris and I. felina showed a negative inotropic effect to approximately the same extent as that from Tochukaso. These three extracts also showed inhibitory action on twitch response of guinea-pig ileum and aggregation of human blood platelet. It is suggested that these activities are ascribed to the combination of adenosine, 5'-adenosine monophosphate and several other nucleic acid-related compounds, all of which have been shown to be present in the extracts.

Solitary polyclonal autonomous thyroid nodule: a rare cause of childhood hyperthyroidism

Solitary autonomous thyroid tumors are an unusual cause of hyperthyroidism, particularly in childhood. We describe the youngest individual so far reported with this condition, a 22 month child with a large hyperfunctioning thyroid nodule who became overtly hyperthyroid after iodinated contrast administration. The histology of the nodule was compatible with follicular cell hyperplasia. These tumors are often called toxic adenomas, although there is no solid evidence that they are true neoplasms. We examined the clonal composition of the child's thyroid tumor by X-chromosome inactivation analysis, taking advantage of a polymorphism in the X-chromosome gene phosphoglycerate kinase. The tumor consisted of an even mixture of cells containing activated paternal and maternal PGK alleles, indicating that the tumor was polyclonal. Furthermore, the nodule had no structural rearrangements or activating point mutations of ras oncogenes, which are found in up to 50% of solitary monoclonal follicular adenomas. Solitary hot nodules may at least in some cases be secondary to hyperplasia, and not to clonal expansion of an abnormal, mutated cell. This may also explain the relatively low frequency of malignant transformation observed in hyperfunctioning thyroid tumors.

[Mechanical valve thrombosis in the tricuspid position--reoperative management of 2 cases]

Because valve thrombosis occurred after the tricuspid valve replacement with the mechanical valve, we performed replacement of the mechanical valve with the bovine pericardial valve in two cases. Case 1: The patient, at 13 years old, received open-heart surgery to correct infundibular stenosis. At 23 years of age, decortication and tricuspid valve replacement (TVR) with a phi 31 mm Björk-Shiley valve were performed due to constrictive pericarditis and tricuspid regurgitation developed after the initial operation. Thrombosis of the mechanical valve occurred after the TVR. Treatment with urokinase for the thrombolytic therapy failed to improve the valve opening. Finally 12 years after the TVR, replacement of the mechanical valve with a phi 27 mm Carpentier-Edwards bovine pericardial valve was performed. Case 2: The patient, at 21 years old, received open-heart surgery to close an atrial septal defect. At 40 years of age, mitral and tricuspid valve replacements were performed because regurgitation developed in both valves. The mitral and tricuspid valves were replaced with phi 27 mm and 31 mm St. Jude Medical valves, respectively. Thrombosis of the mechanical valve used for the TVR occurred 2 months after the replacement. The mechanical valve was replaced with a phi 27 mm Carpentier-Edwards bovine pericardial valve. In both cases, subjective symptoms improved and prosthetic valve complications did not occur after re-replacement with the bovine pericardial valve. These cases suggested that for TVR a bovine pericardial valve of sufficient size would be better to select than a mechanical valve.

Changes of hippocampal glucose utilization subsequent to amygdaloid-kindled generalized seizures

Local changes in cerebral glucose utilization during the postictal phase of amygdaloid-kindled generalized seizures were studied with the quantitative autoradiographic 2-[14C]deoxyglucose method in conscious rats. Measurement was initiated either just after termination of a behavioral seizure (GS-I) or 30 s after seizure termination (GS-II) to determine dynamic metabolic changes in the postictal phase. Although glucose utilization of the neocortex was remarkably depressed in both GS-I and GS-II, that of the hippocampus significantly increased in GS-I and then decreased in GS-II as compared with control. These changes of hippocampal glucose utilization were observed in all sectors of the pyramidal cell layer (CA 1-4) and in the molecular layer. Because metabolic changes associated with development of amygdaloid-kindled seizures begin in the limbic structures including the hippocampus, the transient increase in hippocampal glucose utilization observed in the early postictal phase indicates that the hippocampus is one of the key structures not only for initiating and maintaining but also for terminating kindled seizures.

Assignment of human porphobilinogen deaminase to 11q24.1----q24.2 by in situ hybridization and gene dosage studies

In situ hybridization and gene dosage-effect studies were conducted to determine the detailed chromosomal location of the gene encoding human porphobilinogen deaminase (PBGD). Red cell PBGD activity was normal in one patient with monosomy for 11q24.2----qter but was increased 1.5 times in another patient with trisomy for 11q22.2----qter. The cDNA probe for PBGD was found to be specifically hybridized to band 11q24. These results suggest that the gene for PBGD is localized within the region 11q24.1----q24.2.

[Thyroid carcinoma]

It is now widely accepted that human neoplasms arise as a result of a sequence of mutations affecting the structure of genes involved in growth control. In humans, indirect measurements based on age dependent tumor incidence predict that, on average, the accumulation of 5 to 6 different steps is needed to initiate tumor formation. These mutations do not appear to be random, in that certain neoplasms show prediction for structural aberrations in specific genes. In thyroid tumors, some of gene abnormalities were found. The point mutations of ras oncogenes, predominantly H-ras codon 12, are found in 20-25% of follicular adenomas and papillary carcinomas. Recently, the gene rearrangements of the oncogenes trk and ret were identified in the DNA from papillary carcinomas. About 25% of papillary carcinomas contained an introchromosomal (10q) gene rearrangement involving the tyrosine kinase domain of the ret oncogene with an unknown amino-terminal sequence. The mutations of trk and/or ret were not observed in other thyroid neoplastic phenotypes. In medullary thyroid carcinoma, which is a tumor of the parafollicular, calcitonin-secreting C cell of the thyroid, approximately 20% of patients have autosomal dominant inherited forms. Germ line abnormalities on chromosome 10 are linked to at least one type of genetic medullary thyroid carcinoma (MEN type 2a). In the present time, the person who has the abnormality of gene causing MEN type 2a is able to detect by using DNA marker before the onset of tumor.

Lack of evidence for the presence of human immunodeficiency virus type 1-related sequences in patients with Graves' disease

The pathogenesis of human autoimmune diseases, including Graves' disease, remains to be elucidated. Recently, Ciampolillo et al. proposed that human immunodeficiency virus type 1 (HIV-1)-related retroviruses were involved in Graves' disease. Using Southern blot analysis, they found specific integration of exogenous sequences homologous to HIV-1 gag region in genome DNA of thyrocytes and peripheral blood lymphocytes (PBL) of patients with Graves' disease. In order to test their hypothesis, we examined the presence or the absence of HIV-1 gag-related sequences in Japanese Graves' patients using the polymerase chain reaction (PCR) in addition to Southern blotting. Sets of primer pairs used in PCR were designed to cover the whole span of the HIV-1 gag region. Hybridization was performed in both relaxed and stringent conditions. Our results showed that neither Southern blot hybridization nor PCR gave positive signals in any of the samples examined from Graves' patients. This suggests that HIV-1 or its closely associated viruses are unlikely to be involved in the pathogenesis of Graves' disease in Japan.

Point mutations of ras oncogenes are an early event in thyroid tumorigenesis

Identifying the nature of the genetic mutations in thyroid neoplasms and their prevalence in the various tumor phenotypes is critical to understanding their pathogenesis. Mutational activation of ras oncogenes in human tumors occurs predominantly through point mutations in two functional regions of the molecules, codons 12, 13 (GTP-binding domain) or codon 61 (GTPase domain). We examined the prevalence of point mutations in codons 12, 13, and 61 of the oncogenes K-ras, N-ras, and H-ras in benign and malignant human thyroid tumors by hybridization of PCR-amplified tumor DNA with synthetic oligodeoxynucleotide probes. None of the eight normal thyroid tissues harbored point mutations. Four of nineteen nodules from multinodular goiters (21%), 6/24 microfollicular adenomas (25%), 3/14 papillary carcinomas (21%), and 0/3 follicular carcinomas contained ras point mutations. The predominant mutation was a valine for glycine substitution in codon 12 of H-ras. None of the multinodular goiter tumors known to be polyclonal (and thus due to hyperplasia) had point mutations, whereas one of the two monoclonal adenomas arising in nodular glands contained in H-ras codon 12 valine substitution, which was confirmed by sequencing the tumor DNA. These data show that ras activation is about equally prevalent in benign and malignant thyroid neoplasms, and thus may be an early event in the tumorigenic process.

H-ras protooncogene mutations in human thyroid neoplasms

Structural alterations of protooncogene sequences may be involved in the pathogenesis of human neoplasms. We screened 54 thyroid tumors (36 benign and 18 malignant) for gene rearrangements of the protooncogenes c-myc, c-myb, c-fos, c-erb-B1, c-erb-B2, c-erb-A, N-ras, K-ras, and H-ras. Only mutations of H-ras were observed. None of the 15 colloid adenomas examined had detectable H-ras rearrangements. Of the remaining tumors, we observed mutations of H-ras in 4 benign and 4 malignant neoplasms. Gene amplification was found in 5 tumors. An aggressive recurrent papillary carcinoma had a marked amplification of one of the H-ras alleles. The amplified allele was truncated, in that the 3' variable tandem repeat was not a part of the amplification unit, and contained a codon 12 point mutation leading to a valine for glycine substitution. We also observed the association of low copy gene amplification with a codon 12 valine for glycine mutation in a follicular adenoma. Two tumors contained H-ras EcoRI polymorphisms not present in the DNA of normal thyroid from the same individuals, and one follicular carcinoma showed loss of an H-ras allele. Ras protooncogenes may become transforming by quantitative mutations, leading to increased expression, or qualitative mechanisms, through activating point mutations. Both of these appear to coexist in thyroid neoplasms, and it may be that a combination of both mechanisms is capable of inducing a more complete spectrum of neoplastic phenotypes.

[Frozen blood from one closely related donor reduced complications of blood transfusion without adverse effects in the open-heart surgery]

We used frozen blood from one closely related donor in 24 patients (group I) who underwent open heart surgery for congenital heart disease, in order to reduce of complications from a large quantity of blood transfusion. Blood of 600-2200 ml was collected from the single donor and was kept frozen until the operation. Two conditions of the patients were instituted, (1) body weight less than or equal to 40 kg (2) the single donor is father or mother or a close relative. The group of these patients was compared with patients using frozen autologous blood (group II) and patients using banked blood (group III). In group I patients two times of decline of red blood cell counts (RBC), hematocrit (Ht), hemoglobin (Hb) and total protein (TP) were noticed. The first was the period during the cardio-pulmonary bypass. The second was the time about one week after the transfusion of frozen red cells. But degree of the decline was uneventful clinically. The increment of complications induced from the use of frozen red cells was not noticed, and there was no case of serum hepatitis in group I patients. We concluded that the open-heart surgery using frozen blood cells (single donor), if the application was appropriate, could be undergone safely and would be effective on reducing infection and reaction induced from blood transfusion.

Clonal composition of benign and malignant human thyroid tumors

We determined clonality of thyroid tumors from female patients who had restriction fragment length polymorphisms (RFLP) in the X chromosome genes hypoxanthine phosphoribosyltransferase (HPRT) or phosphoglycerate kinase (PGK). We screened normal thyroid tissue from 59 female patients; of the informative cases 14 were heterozygous for a Bgl I site on PGK and 4 were heterozygous for a Bam HI site on HPRT. In monoclonal tumors, one of the polymorphic alleles was selectively digested after additional digestion with Hpa II, a methylation sensitive enzyme, whereas in polyclonal tissue both were decreased to a similar extent. Normal thyroid tissue from all patients showed a polyclonal pattern. Of the 18 tumors studied, 12 were solitary thyroid nodules, and 6 were obtained from multinodular goiters (MNG). The following were monoclonal: 6/6 follicular adenomas, 2/2 follicular carcinomas, and 1/1 anaplastic carcinoma. Two of the three papillary carcinomas showed intermediate patterns, possibly due to contaminating effects of stromal tissue present in most of these neoplasms. Of the six nodules from MNG, four were polyclonal. The two largest gave a distinct monoclonal pattern. Most solitary thyroid tumors are monoclonal, supporting a somatic cell mutation model of thyroid neoplasm formation. Nodules from MNG are largely hyperplastic, although monoclonal neoplasms do occasionally arise within these glands. The specific somatic mutations leading to clonal expansion and determination of tumor phenotype are presently unknown.

[Post-operative evaluation of a 17 mm diameter Björk-Shiley Monostrut prosthesis for aortic valve replacement--pressure gradient and effective valve area]

A 17 mm diameter Björk-Shiley Monostrut prosthesis was implanted in a 64-year-old female for aortic valve replacement in a semi-emergency. This valve was one of the smallest valves which were available in Japan. The patient was admitted because of severe hemolytic anemia and heart failure. Echocardiography showed regurgitation and calcification of Ionescu-Shiley tissue valve which was implanted 5 years ago. The patient's body surface area was 1.2 m2. Because of narrow aortic annulus, we could barely implant a 17 mm diameter Björk-Shiley Monostrut prosthesis. The valve function was examined by Brockenbrough method. During catheterization, the heart rate was 85 b/min and cardiac index was 3.00 l/min/m2. In these hemodynamic conditions, simultaneous measurements of aortic and left ventricular pressures revealed only 9 mmHg mean systolic pressure gradient. Similarly, 20 mmHg of pressure gradient across the implanted valve was obtained by Gorlin's formula. We could calculate that the effective orifice area of a 17 mm diameter Björk-Shiley Monostrut prosthesis was 1.0 cm2. Postoperative echocardiography demonstrated 42 mmHg systolic pressure gradient across this prosthesis by Doppler techniques, and left ventricular wall thickness was not decreased. To best our knowledges, this was the first case in which post-operative evaluation such a small prosthesis was measured.

[A case of modified Fontan operation for complete atrioventricular canal of right dominance with double-outlet right ventricle, common atrioventricular valve regurgitation]

A 6-year-old boy was diagnosed to have complete atrioventricular canal (CAVC) with double-outlet right ventricle (DORV), common atrium and common atrioventricular valve regurgitation. The atrioventricular junction predominantly connected to the right ventricle (right dominance) and the left ventricle was hypoplastic (LVEDV = 64% of normal). The combination of DORV with right dominant CAVC makes more difficult to make intra-ventricular rerouting. A modified Fontan procedure, atrial partition and DeVega's annuloplasty were successfully performed. It is concluded that Fontan procedure might be preferable rather than intra-ventricular rerouting in this case.

Loss of the 3p25.3 band is critical in the manifestation of del(3p) syndrome: karyotype-phenotype correlation in cases with deficiency of the distal portion of the short arm of chromosome 3

Two patients with monosomy for the distal portion of the short arm of chromosome 3 are described. Chromosome analysis on prometaphase cells demonstrated a karyotype of 46,XX,del(3) (p25.3) in one patient and 46,XX,r(3)(p26.1q29) in the other. The former patient showed characteristic clinical manifestations of the 3p- syndrome, including growth failure, mental retardation, microcephaly with a flat occiput, triangular face, synophrys, blepharoptosis, hypertelorism, broad and flat nose, long philtrum, down-turned mouth, micrognathia, apparently lowset and malformed ears, fingers abnormalities, and deafness. The latter patient had a nonspecific phenotype with mental retardation, growth failure and microcephaly. Karyotype-phenotype comparisons in the present cases and 16 previously reported cases with deficiency of the distal portion of 3p suggests that deficiency of the 3p25.3 band is critical to produce the main clinical manifestations of the del(3p) syndrome.

Spreading depression following experimental head injury in the rat

The direct current (DC) potential and electroencephalographic (EEG) changes were continuously monitored following fluid percussion head injury (brain contusion) in 10 conscious rats. Local cerebral glucose utilization (LCGU) was measured by the autoradiographic [14C]deoxyglucose method. Measurement of LCGU was started at the lowest point of the first or second DC potential negative shift when it occurred, and 2 hours after contusion if no DC potential changes were observed. The DC potential did not change in four rats (Group A), whereas DC potential negative shifts together with marked suppression of EEG activity occurred at 54 +/- 6.9 minutes after injury in six rats (Group B). In Group A, LCGU was decreased nonsignificantly in both the right and left cortices. In Group B, however, LCGU in the lesioned cortex rose to 160-190% of the level observed in the contralateral cortex (p less than 0.05). The autoradiographic pattern in Group B was identical to that seen in spreading depression. These findings can contribute to the effort to better understand the pathophysiology of head injury.

[Surgical repair and late problem for Ebstein's anomaly--surgical cases with severe tricuspid stenosis or regurgitation]

In this report, we described our surgical experiences of Ebstein's anomaly with severe tricuspid stenosis (TS) or regurgitation (TR). Long-term clinical assessments and late problems of the treatment were also mentioned. From 1953 to 1988, a total of 2850 patients with congenital heart malformation underwent surgery in our hospital. During this period, 32 patients with Ebstein's anomaly were admitted, and surgical treatment was performed in 10 of these patients. Thus, the surgical treatment of Ebstein's anomaly took only 0.35% of total surgeries of congenital heart diseases. According to Takayasu's classification of Ebstein's anomaly, 6 of our these patients were classified into TS, and 4 into TR type. The operative methods were shunt operation in 3 patients, plication in 2 patients and tricuspid valve replacement (TVR) in 5 patients. One patient was died during the operative course of Glenn's procedure. Other 9 patients are alive and the longest follow-up period is 18 years at this moment. In the remaining two patients with shunt operation, Blalock-Taussig's procedure completely diminished their polycythemia. In the cases of TVR, the replaced valve was sutured to the right atrium in 2 patients with TS, true annulus in 2 patients with TR, valve remnant in one patient with TR type. Delayed cardiac tamponade occurred in 2 patients and calcification of Xenograft valve was observed at 8 years after the surgery in one patient with TVR. Although the hemodynamics did not improve immediately just after open heart surgery, cardio-thoracic ratio reduced and clinical symptoms were improved remarkably throughout the long-term follow-up.(ABSTRACT TRUNCATED AT 250 WORDS)

[Changes in local cerebral glucose utilization, DC potential and extracellular potassium in various degree of experimental cerebral contusion]

Pathophysiology of the traumatized brain, especially that of cerebral contusion, is very complex and has not been well understood. In recent years, changes in extracellular ion concentration have been known in various pathological conditions such as cerebral concussion, spinal contusion, ischemia, hypoglycemia, epilepsy and spreading depression as one of the triggers to lead to secondary brain damage. To know the metabolic and ionic changes following cerebral contusion, the authors made various degree of cerebral contusion by fluid percussion method, and observed successive changes in EEG, DC potential, extracellular potassium concentration and local cerebral glucose utilization (LCGU).

MATERIALS AND METHODS

Using 42 male Wistar rats, mild (0.2 kg/cm2), moderate (0.4 kg/cm2) and severe contusion (0.6 kg/cm2) were made in the left lower parietal region of the rats. EEG, DC potential and extracellular potassium concentration (using potassium sensitive glass microelectrode) were monitored for four to five hours after making the contusions. LCGU (by 14C-2-deoxyglucose method) was studied at the time of the negative shift of DC potential.

RESULTS

The negative shift of DC potential with EEG suppression was observed at 30 min. to 3 hours after injury. The severer the injury was, the earlier and the more frequent negative shifts appeared. LCGU showed no significant changes in the mild injury group. In the moderate injury group, frequent negative shifts of DC potential associated with EEG suppression were observed. A 20% increase of glucose utilization in the cortex of the lesion side was observed whereas 50% decreases in the subcortical structures were found. In the severe injury group, EEG was suppressed immediately after contusion and had never recovered. DC potential fluctuated and was unstable. The increase of LCGU was noted not only in the cortex of the lesion side but also in some of the subcortical structures (hippocampus, caudate nucleus, dentate nucleus and thalamus). The extracellular potassium concentration rose to 30 mM, being correlated closely with DC potential.

DISCUSSION

Increase of LCGU associated with EEG suppression, negative shift of DC potential and elevation in extracellular potassium concentration was thought to be due to spreading depression. It was postulated that spreading depression following cerebral contusion causes energy failure and can lead to secondary brain damage.

[A case report of emergency thoracotomy and aortic cross clamp for massive abdominal hemorrhage due to the rupture of a pancreatic pseudocyst]

The authors present a rare case of a 58-year-old female who had cardiac arrest due to massive abdominal hemorrhage because of the rupture of pancreatic pseudocyst during an emergency operation. We succeeded in resuscitation by performing emergency thoracotomy and internal cardiac compression. Thoracic aortic cross clamping was employed to control bleeding, and we could perform the operation. She recovered without any neurological deficits. Thoracic descending aortic cross clamping should be always considered both before and during operation for the control of massive abdominal hemorrhage to avoid circulatory collapse.

Local cerebral glucose utilization in the postictal phase of amygdaloid kindled rats

Local cerebral glucose utilization was measured by means of the quantitative autoradiographic 2-[14C]deoxyglucose method during the postictal phase of various seizure stages of amygdaloid kindling in conscious rats. The partially kindled animals exhibited a partial seizure such as chewing and/or head nodding, and the fully kindled animals, a generalized tonic-clonic convulsion. The control animals were implanted with an electrode, but not electrically stimulated. Cerebral glucose utilization of the fully kindled animals was deeply depressed in the postictal phase as compared to the control, and that of the partially kindled animals was moderately decreased. The side-to-side differences of cerebral glucose utilization were observed only in the partially kindled group in which glucose utilization was more depressed on the side of stimulation. Among the structures with depressed glucose utilization, only one structure, the interpeduncular nucleus, showed a relative increase in glucose utilization during the postictal phase of the kindled groups. As the postictal phase has been considered as a period of inhibition, these results may indicate that the neural networks linking the interpeduncular nucleus play an active role in the mechanisms of termination of a seizure and postictal refractoriness.

Insulin-like growth factor-I action on growth hormone secretion and messenger ribonucleic acid levels: interaction with somatostatin

Insulin-like growth factor I (IGF-I) suppresses GH gene transcription and GH secretion, while somatostatin (SRIF) only suppresses GH secretion. The interaction of these inhibitors of GH was, therefore, tested in primary rat pituitary cells grown in serum-free medium. Maximal inhibition of GH secretion (to 30% of the control value) was achieved by 13 nM IGF-I, while 5 nM SRIF suppressed GH to 36% of control secretion. The respective ED50 values for IGF-I and SRIF inhibition of GH secretion were similar (approximately 2.5 nM). Treatment of cells with the two agents together resulted in a further inhibition of basal GH secretion to 18% of control untreated cells (P less than 0.005). Increasing doses of SRIF (2.5-10 nM) in the presence of IGF-I caused a dose-dependent suppression of GH secretion. PRL levels were not altered by these treatments, indicating a selective effect on GH. GRH-induced GH secretion was further attenuated by combined IGF-I and SRIF treatment compared to the effect of either of these two agents alone. Northern analysis showed that IGF-I suppressed GH mRNA transcripts, while SRIF did not alter GH mRNA levels. The results indicate that physiological concentrations of both IGF-I and SRIF suppress long term basal GH secretion. Only IGF-I alters GH mRNA levels. These two peptides, therefore, appear to attenuate in vitro GH secretion by different mechanisms.

Hypermetabolic state following experimental head injury

Local cerebral glucose utilization (LCGU) was studied in 35 conscious rats after a fluid percussion injury (cerebral contusion). The experiments were divided into two parts. (I) Natural course: LCGU was quantitatively measured in 17 rats by the 14C-deoxyglucose autoradiographic method (Sokoloff et al. 1977) at 1, 2, 4 and 24 hours after injury. Sham operation was made in six rats. (II) DC-potential and LCGU: LCGU was studied with DC-potential and EEG monitoring in 12 rats. Results were as follows: (I) i) Glucose uptake was reduced at the center of the contusion in all cases. ii) Two different effects were observed in LCGU change two hours after injury: normal or slight increase in four of six rats (type A) and a remarkable increase in the cortex of the injured hemisphere in two of six rats (type B). iii) The pattern of increase in LCGU (type B) resembles that of cortical spreading depression. (II) i) Negative shift of DC-potential concomitant with EEG suppression in the injured hemisphere was observed frequently one to two hours after injury. ii) The increased LCGU pattern during DC-potential negative shift was identical with that of type B. iii) LCGU pattern without DC-potential change resembles that of type A. We concluded that the hypermetabolism occurring in the damaged cortex was due to a spreading depression. The findings obtained here should yield very important information concerning pathogenesis and treatment of human head injury.

Changes of local cerebral glucose utilization, DC potential and extracellular potassium concentration in experimental head injury of varying severity

The negative shift of DC potential was associated with an increase of extracellular potassium and energy metabolism. Therefore this dramatic phenomenon following the trauma to the brain was thought to be identical to spreading depression. 1. Spreading depression was most frequently observed between one and two hours after injury. 2. Spreading depression can be elicited in the deep structures as well as in the cortex. The more severe the injury, the more frequently the negative shifts were observed. The DC index seems to correlate well with the severity of the experimental model. It is concluded that the energy metabolism after the brain contusion was different from structure to structure and was changing continuously in the course of time.

Reperfusion through balloon catheter to minimize myocardial infarction during the interval between failed percutaneous transluminal coronary angioplasty and emergency coronary artery bypass grafting

A 65-year-old man was admitted with chest pain. A diagnosis of spastic angina was made because of symptoms of recurrent anginal attacks associated with ST-segment elevations in the electrocardiogram. A selective coronary arteriogram revealed a 90% diameter narrowing of the proximal left anterior descending coronary artery (LAD). No angiographically visible collaterals from the right coronary artery to the LAD were observed. The ventriculogram showed normal contraction of the left ventricle with an ejection fraction of 65%. Percutaneous transluminal coronary angioplasty (PTCA) failed resulting in total occlusion of the stenosis. Repeat PTCA at a higher pressure and of longer duration failed to redilate the artery. Reperfusion with the blood from the femoral artery through the balloon catheter, which was used for the PTCA, was carried out until coronary artery bypass grafting (CABG). Blood flow rate of perfusion was approximately 25 ml/min. Reperfusion through the balloon catheter reduced chest pain and ST-segment elevations in the electrocardiogram. The patient tolerated the operative procedure well and his post-operative course was uncomplicated. The interval between the acute occlusion and revascularization by CABG was approximately 4 1/4 h. The ventriculogram taken 56 days after the CABG demonstrated normal contraction of the anterior wall of the left ventricle with an ejection fraction of 63%. Abnormal Q waves did not appear in precordial leads of the electrocardiogram after the surgery. The thallium scintigram showed no perfusion defects. In conclusion, this case suggested that autologous blood reperfusion through balloon catheter would be worth attempting in some cases for minimization of myocardial infarction during the interval between failed PTCA and emergency CABG.

Post-traumatic intention tremor--clinical features and CT findings

Eight patients with post-traumatic intention tremor were reported. Intention tremor developed in the young as a late complication of severe head injury (Glasgow Coma Scale was below 8 in all cases) and impaired their functional outcome. This state was treatable with medication or by stereotactic thalamotomy. Neurologically, all the patients lapsed into coma immediately after the injury and many patients manifested clinical signs of a midbrain lesion in the chronic stage. The characteristic CT (computed tomography) findings in the acute stage were a high density area in the midbrain, accompanied by diffuse cerebral swelling or intraventricular hemorrhage, and in the chronic stage, brain atrophy or ventricular enlargement were the most prominent CT findings. These characteristics, indicating diffuse brain damage in addition to midbrain injury, may suggest the presence of shearing injury. The midbrain damage is consistent with the classical hypothesis that the damage to the Dentate-Rubro-thalamic system accounts for the occurrence of intention tremor. Furthermore, the presence of diffuse brain damage suggests that a more widespread brain injury may participate in its development.

[Intention tremor after head injury. Clinical features and computed tomographic findings]

Eight cases of intention tremor as a late complication of head injury were investigated. The patients ranged in age from 3 to 24 years. All received severe head injuries and lapsed into coma immediately afterward (Glasgow Coma Scale scores less than or equal to 8). Six patients exhibited decerebration or decortication. Hemiparesis was present in six cases and oculomotor nerve palsy in four. In the chronic stage, all patients displayed some degree of impairment of higher cortical function and five had dysarthria and/or ataxia. Initial computed tomography (CT) scans within 3 hours after the injury were obtained in five cases, of which four showed a hemorrhagic lesion in the midbrain or its surroundings. Other CT findings were diffuse cerebral swelling (four cases), intraventricular hemorrhage (three), and multiple hemorrhagic lesions (two). In the chronic stage, generalized cortical atrophy or ventricular enlargement was noted in five cases. These clinical features and CT findings indicate diffuse brain damage as well as midbrain damage and may reflect shearing injury.

[Emergency operation in impending rupture of aortic arch dissecting aneurysm--a case report of dissecting aortic aneurysm with adhesion to the lung after lobectomy]

Successful surgical treatment of impending rupture of a aortic arch dissecting aneurysm in a 59-year-old man was reported. The aneurysm was tightly adhered to the lung, because he had a previous history of lobectomy. In this case, the permanent aortic bypass with permanent aortic clamp as a means of exclusion procedure of the aortic aneurysm was effective. The postoperative course was uneventful. In the emergency operation for aortic arch aneurysm, operative procedure should be selected by operative findings and risk.

Local cerebral glucose utilization in controlled graded levels of hyperglycemia in the conscious rat

Local cerebral glucose utilization assayed by the [14C]deoxyglucose ([14C]DG) method and calculated by means of its operational equation with values for the rate constants and lumped constant determined in rats under physiological conditions remains relatively stable with variations in arterial plasma glucose concentration within the normoglycemic range. Large changes in arterial plasma glucose level may, however, significantly alter the values of these constants and lead to artifactual results. Values for the lumped constant have been measured and reported for a wide range of arterial plasma glucose concentrations ranging from hypoglycemia to hyperglycemia in the rat (Schuier et al., 1981; Suda et al., 1981; Pettigrew et al., 1983). In the present study we have redetermined the rate constants in rats with arterial plasma glucose levels clamped at approximately 350, 450, and 550 mg/dl (i.e., 19, 25, and 31 mM) by a glucose clamp technique. The rate constants for the transport of DG from plasma to brain, K1*, and its phosphorylation in tissue, k3*, were found to decline with increasing plasma glucose levels, while the rate constant for its transport back from brain to plasma, k*2, remained relatively unchanged from its value in normoglycemia. These rate constants were used together with the previously determined values for the lumped constants to calculate local rates of cerebral glucose utilization in three groups of rats in which arterial plasma glucose levels were clamped at approximately 350, 450, and 550 mg/dl (i.e., 19, 25, and 31 mM). Average glucose utilization in the brain as a whole was unchanged in hyperglycemia from the values calculated in normoglycemic rats with the standard normal set of constants. Changes in the rate of glucose utilization were found, however, in the hypothalamus, globus pallidus, and amygdala during hyperglycemia.

The effects of mazindol on local cerebral glucose utilization in rats

The effects of mazindol (1 mg or 10 mg/animal, p.o.) on local cerebral utilization of glucose were studied by the quantitative autoradiographic [14C]2-deoxyglucose method in conscious adult male rats. Significant increases in local cerebral utilization of glucose were observed 2 hr after administration of 10 mg of mazindol in 10 out of 37 anatomically discrete regions examined. These 10 areas included regions rich in dopaminergic receptors (substantia nigra, globus pallidus), and also regions with few dopaminergic receptors (cerebral cortex, thalamus, cerebellum). Only the habenular nucleus showed a significant decrease in utilization of glucose induced by the administration of 10 mg of mazindol. No significant changes in local cerebral utilization of glucose were observed following the administration of 1 mg of mazindol. The fact that the pattern of utilization of glucose observed in this study resembled that produced by apomorphine, a putative dopaminergic agonist, indicates that the pharmacological effects of mazindol are related to the dopaminergic system.

Effects of insulin on local cerebral glucose utilization in the rat

The effects of hyperinsulinemia on local cerebral glucose utilization were studied by the quantitative autoradiographic 2-[14C]deoxyglucose method in normal conscious rats under steady-state normoglycemic conditions. Hyperinsulinemia and a steady state of normoglycemia were achieved and maintained during the experimental period by a continuous intravenous (i.v.) infusion of insulin given simultaneously with a programmed i.v. infusion of D-glucose. Hyperinsulinemia under normoglycemic conditions did not change the average rate of glucose utilization in the brain as a whole, but significant increases in local glucose utilization were found selectively in the ventromedial, dorsomedial, and anterior hypothalamic nuclei. The results suggest that a known anatomical pathway linking the dorsomedial and anterior nuclei with the ventromedial nucleus of the hypothalamus may be physiologically activated in response to hyperinsulinemia.