Continuous transoesophageal echocardiography monitoring during weaning from cardiopulmonary bypass in children

The purpose of this study was to evaluate the effectiveness of transoesophageal echocardiography monitoring during weaning from cardiopulmonary bypass after intracardiac repair in children. The left ventricular ejection fraction, left ventricular end-diastolic volume and left ventricle wall motion were monitored continuously by transoesophageal echocardiography in controls weaned easily from cardiopulmonary bypass (group A, n = 25), and those weaned with difficulty from cardiopulmonary bypass after mechanically assisted circulation (group B, n = 16). In group A, left ventricular ejection fraction and left ventricle wall motion were within normal range, and did not change significantly during weaning after cardiopulmonary bypass when compared with pre-bypass data. In contrast, left ventricular ejection fraction, left ventricular end-diastolic volume and left ventricle wall motion in group B during the first trial of weaning from bypass were significantly worsened. Hence, assisted circulation was performed until the data obtained via transoesophageal echocardiography improved with regard to maintenance of fluid balance, catecholamine dosage and assisted pump flow. All cases in group B were weaned safely from cardiopulmonary bypass despite their critical condition. In conclusion, continuous transoesophageal echocardiography monitoring may be a useful tool in children with severe heart failure for safe weaning from cardiopulmonary bypass after intracardiac repair.

Infective endocarditis. Considerations for the timing of surgical intervention and type of infecting microorganism

To determine the appropriate timing for surgical intervention in infective endocarditis (IE), we evaluated 24 patients (17 males, 6 females, with one included twice) who underwent surgical intervention for IE of native valves (NVE, n = 21) and prosthetic valves (PVE, n = 3) between January 1989 and September 1994. The mean age was 41 +/- 13 years (range 6 to 64 years). The most common infective organisms were Staphylococcus (33% of NVE) and Streptococcus (19% of NVE), with five NVE patients (24%) negative for blood culture. The PVE patients showed a different pattern of infecting organisms, with Enterococcus in one and Pseudomonas in another. From the resected valve culture and pathological findings, 12 patients were in the active stage at operation. Two in-hospital deaths occurred for a mortality rate of 8.7% (2/23). Further, surgical interventions were performed earlier with Staphylococcal infections than with Streptococcal infections, because hemodynamic compromise presented more progressively in the former. Also resected valve cultures and the pathological findings showed that a persistent infectious process existed in many cases of Staphylococcal infection in spite of intensive antibiotic therapy. In conclusion, we suggest that internists make referrals for surgical intervention for patients with NVE or PVE as early as possible in the active stage of infection.

Production of the immunosuppressive cytokine interleukin-10 by Epstein-Barr-virus-expressing pyothorax-associated lymphoma: possible role in the development of overt lymphoma in immunocompetent hosts

Malignant lymphomas frequently develop in the pleural cavity of patients with long-standing pyothorax. Thus, the term pyothorax-associated lymphoma (PAL) has been proposed for this type of tumor. Most PALs are diffuse lymphomas of B cell type and contain Epstein-Barr virus (EBV) DNA. We have established two lymphoma cell lines from the biopsy specimens of PAL cases, OPL-1 and OPL-2. Both cell lines contain EBV DNA, but only OPL-1 expresses EBV nuclear antigen 2, which works as a target molecule for the cell-mediated immune response. As systemic immunodeficiency is unlikely to be present in PAL patients, PAL from which OPL-1 derived was not expected to be fully developed. In this study, we examined the expression of immunosuppressive factors in OPLs. Only OPL-1, not OPL-2, expressed interleukin-10 (IL-10) mRNA and secreted IL-10 into culture supernatant. Both OPL-1 and OPL-2 expressed transforming growth factor (TGF)-beta 1 mRNA; however, neither expressed latent TGF-beta-binding protein mRNA at a detectable level by Northern blot analysis. Because TGF-beta expresses its functions in cooperation with latent TGF-beta-binding protein, the biological functions of TGF-beta 1 could be negligible. Neither cell line expressed at a detectable level EBV BCRF-1 mRNA, a viral gene product that is partly homologous to human IL-10 and shares biological activities of IL-10. Although IL-10 is reported to promote the growth of activated or neoplastic B cells, OPL-1 did not respond to human recombinant IL-10 by growing faster. As OPL-1 expresses a target antigen for the host cytotoxic T-cell response, the production of an immuno-suppressive cytokine, IL-10, might contribute to the development of overt lymphoma by inducing locally immunosuppressive circumstances. The present study suggests that an immunosuppressive cytokine plays a role in lymphomagenesis of immunocompetent patients.

A rapid serological detection method for squamous cell carcinoma

OBJECTIVE

We conjugated the squamous cell carcinoma (CA)-associated antibody (anti-YM antibody) with gelatin particles. We found that these particles reacted specifically with the tumor-associated antigen (YM antigen) in serum samples from patients with squamous cell CA of the uterine cervix and various organs (GPA reaction).

METHODS

1) We performed immunohistochemical studies of the YM antigen in dysplasia and invasive squamous cell CA of the uterine cervix; 2) We measured the GPA reaction in various malignant and non-malignant gynecologic diseases.

RESULTS

1) Immunohistochemical localization of the YM antigen was over 75% in cases of dysplasia and invasive squamous cell CA of the uterine cervix, and was 21% in normal squamous epithelium of the uterine cervix. 2) The GPA reaction in gynecologic diseases was positive in 57.1% of the dysplasia cases; in CIS cases, 69.2%; in cervical CA, 83.0%; in corpus CA, 25.0%; in leiomyoma 16.7%; and in pregnant serum samples, 66.7%, 3) GPA reactions in non-ob-gyn cases were positive in 68.8% of the cases of squamous cell CA of the head and neck; 66.7% in cases of squamous cell CA of the lung; and 25.0% in adenoCA of the lungs whereas the sera of patients with benign tumors and of healthy persons were free of the YM antigen.

CONCLUSION

We concluded that this newly developed GPA-reaction measurement is a simple and reliable serologic test for detecting the initial stage of squamous cell CA of various organs and for monitoring its postoperative status.

Aortic dissection extending from the left coronary artery during percutaneous coronary angioplasty

A 72-year-old woman with acute aortic dissection as a complication of percutaneous coronary angioplasty was successfully treated. She received a graft replacement of the ascending aorta as well as triple coronary artery bypass grafts. The dissection had extended from the left coronary artery. Although acute aortic dissection is a rare complication of percutaneous coronary angioplasty, physicians and cardiac surgeons should keep its potential occurrence in mind.

Interleukin-6-mediated growth enhancement of cell lines derived from pyothorax-associated lymphoma

Malignant lymphomas frequently develop in the pleural cavity of the patients with long-standing pyothorax. Thus, the term pyothorax-associated lymphoma (PAL) has been proposed for this type of tumor. Most PAL are diffuse large cell lymphoma of B cell type that contain Epstein-Barr virus DNA. We have established two lymphoma cell lines from the biopsy specimens of PAL cases, OPL-1 and OPL-2. Because PAL develop in the sites of chronic inflammation, inflammatory cytokines might be involved in the lymphomagenesis. To address this point, we examined the regulation of the growth of OPL by human IL-6. Human recombinant IL-6 enhanced the growth rate of OPL. OPL-1 responded to recombinant IL-6 by growing faster even at concentrations of less than 0.1 ng/ml, whereas OPL-2 required higher concentrations of recombinant IL-6. OPL expressed IL-6 receptor mRNA detectable by reverse transcriptase PCR analysis and IL-6 receptor on cell surface by flow cytometric analysis, using anti-IL-6 receptor antibodies. On the other hand, only OPL-1 showed expression of IL-6 mRNA, which was detectable only by reverse transcriptase PCR, and secreted IL-6 protein into the culture media. The culture supernatant of OPL-1 exhibited growth-enhancing effects on OPL-1 and OPL-2. The addition of anti-IL-6 antibodies to the cultures inhibited the growth of OPL-1 but not OPL-2. OPL-2 did not secrete IL-6 protein into the media, and the culture supernatant from OPL-2 did not enhance growth of OPL-2. These findings suggest the involvement of IL-6 in the growth regulation of OPL, i.e., an autocrine mechanism of IL-6-related proliferation in OPL-1 and a paracrine mechanism in OPL-2. IL-6 locally produced in chronic pyothorax might also promote the development of PAL.

Development of protamine-bonded phase for separation of saccharides in liquid chromatography

A protamine-bonded polymer gel was synthesized by passing this protein through an activated carbamate polyamine polymer gel layer. This new packing material was suitable for versatile separation of monosaccharides, oligosaccharides, sugar alcohols and uronic acids in liquid chromatography. The column packed with this gel could be operated at room temperature and gave excellent recovery for the reducing monosaccharides such as 2-deoxyribose, 2-deoxyglucose, ribose and mannose for which the conventional alkylamine-bonded phase column gave poor recovery. This column was used for the analysis of saccharides in urine using a post-column reaction detection system.

A case report of simultaneous surgery for Wolff-Parkinson-White syndrome combined with hemolytic anemia and mitral stenosis

A 46-year-old woman with mitral stenosis, WPW syndrome, hemolytic anemia due to spherocytosis, and hypothyroidism with Hashimoto's thyroiditis, was admitted with palpitations and dyspnea due to paroxysmal atrial fibrillation with a rapid ventricular response, and was treated by electrical cardioversion. We selected surgical intervention to treat the mitral stenosis and WPW syndrome, as some tachycardia episodes due to atrial fibrillation have resulted in repeated congestive heart failure. In 1983 we simultaneously performed a division of the posteroseptal accessory pathway and a mitral valve replacement with a bioprosthetic valve under cardiopulmonary bypass, using a membrane oxygenator after splenectomy to compensate for the hemolytic anemia due to spherocytosis. Her postoperative course was favorable and she is now in good health with no episodes of tachycardia, congestive heart failure nor anemia occurring during the 10 years that have followed the operation. Simultaneous surgery for WPW syndrome combined with other cardiac abnormalities and hematologic disorders achieved acceptable results in this case.

Immunological and virological study of sudden deafness

Thirty-three patients with sudden deafness and 11 controls were selected from the patients admitted to the Department of Otolaryngology, Tokai University Hospital from November 1990 to October 1991. Viral titers were measured for mumps, adenovirus, rubella, measles, herpes simplex virus (HSV), varicella zoster virus (VZV), rhinosyncytial virus, cytomegalo-virus (CMV), and mycoplasma pneumoniae in 33 sudden deafness patients and 11 controls at a 2-week interval. In 20 of 33 sudden deafness patients and 5 of 11 controls, autoantibodies of rheumatoid factor (RF), anti-mitochondrial antibody (AMA), anti-nuclear antibody (ANA), anti-parietal cell antibody (APA), anti-smooth muscle antibody (ASA), and anti-type II collagen antibody were studied. Viral titer study did not reveal any significant change either in the patients or in the controls, whereas autoantibody study revealed a relatively high incidence for ASA in the patients as compared with the controls. The relatively high incidence for ASA suggests that immune-mediated processes may be involved in the etiology of sudden deafness.

Atrial activation during chronic atrial fibrillation in patients with isolated mitral valve disease

BACKGROUND

A computerized 32-channel mapping system has been developed to investigate the characteristics of the atrial activation sequence. The system is capable of displaying sequential atrial maps and provides a rapid and dynamic means of verifying the activation sequence of atrial fibrillation.

METHODS

Using this system, we performed intraoperative atrial activation mapping in 10 patients with chronic atrial fibrillation who were undergoing isolated mitral valve operations.

RESULTS

Regular and repetitive activation (cycle length ranged from 131 to 228 milliseconds) originated in the left atrium in all 10 patients. Two patterns of repetitive activation in 2 patients and three patterns in 1 patient appeared alternately during the observation period in the left atrium. In contrast to the repetitive activation in the left atrium, the activation sequence of the right atrium was extremely complex and chaotic. In 7 of the 10 patients, the same pattern of right atrial activation was never repeated during the observation period. In 2 patients, revolution of repetitive activation in the right atrium sporadically appeared, but the pattern of activation immediately deteriorated to a complex and chaotic pattern. In 1 patient, repetitive activation emerged from the low lateral portion of the right atrium. Because our mapping technique was limited by the number of available atrial electrodes, discrete reentrant circuits or ectopic foci could not be demonstrated in the present study. However, the activation sequences during chronic atrial fibrillation suggested that (1) the left atrium would act as an electrical driving chamber for atrial fibrillation in the majority of the patients and (2) atrial activation patterns are different in each case.

CONCLUSIONS

Computerized intraoperative mapping should guide surgeons in determining the appropriate surgical procedure and facilitate operation for chronic atrial fibrillation associated with mitral valve disease.

[Sequential coronary artery bypass grafting utilizing the internal thoracic and gastroepiploic artery as in situ grafts]

36 consecutive patients (male:female = 33:3, mean age 57.3) underwent sequential coronary artery bypass grafting (CABG) utilizing the left internal thoracic artery (LITA, n = 30), right gastroepiploic artery (RGEA, n = 8) as in situ grafts. Two patients received sequential bypass grafting with both grafts simultaneously. No right internal thoracic arteries were used except for one as a free nonsequential graft. Taking into account the adjunctive venous anastomoses and the arterial nonsequential anastomoses, there were 3.5 anastomoses per patients. Proxymal side-to-side anastomosis of LITAs were all constructed on the diagonal branches except for one on the proxymal Left Anterior Descending Coronary Artery (LAD), whereas that of the RGEAs were on the proxymal Right Coronary Artery (RCA) (2), distal RCA (6) or distal circumflex (1). Distal end-to-side anastomoses of LITAs were all on the LAD, and those of the RGEAs were on the distal RCA (3) or distal circumflex artery (5). Proxymal side-to-side anastomoses were always performed first, allowing us to assess the distal flow through the graft before we anastomose it to the distal branch. We routinely obtain a preoperative angiogram of the arterial grafts, which enable us to fully assess the suitability of the arteries as in situ grafts. There were no perioperative deaths, nor perioperative myocardial infarctions, however, two patients died of extracardiac causes at 42 and 68 days after operation respectively. For the thirty four survivors, followup was complete (4-49 months, average 12.3 months). One still had angina of Canadian Cardiovascular Society Classification (CCSC) class 2, and 33 were free of angina.(ABSTRACT TRUNCATED AT 250 WORDS)

Nd:YAG laser irradiation in root canal disinfection

The purpose of this study was to assess the efficacy of Nd:YAG laser irradiation in disinfecting the root canal system. Seventy-five teeth were uniformly instrumented and sterilized, and their root canals were infected for 60 min with an overnight culture of Enterococcus faecalis in Tryptic Soy Broth. The teeth were divided into 6 groups: 1--non-infected controls; 2--infected controls; 3--infected, laser treated; 4--infected, laser dummy (dye only); 5--infected, laser dummy (dye and air-water spray); 6--infected, NaOCl-treated (reference group). After treatment, the root canals were dried and dentinal shavings removed for a post-treatment culture. Quantitative analysis of bacteria surviving the various treatments were performed and the bacterial counts for each group were compared. SEM analysis of teeth split longitudinally was used to illustrate the effect of treatment on the smear layer and on surface bacteria. Nd:YAG laser irradiation (group 3) significantly reduced the number of bacteria while NaOCl irrigation (group 6) effectively disinfected the canals.

Preventive effect of pirfenidone against experimental sclerosing peritonitis in rats

We investigated the preventive effect of pirfenidone (PFD), a newly developed anti-fibrotic agent, on experimental sclerosing peritonitis (sp) which we had established in rats. Male Wistar rats (150-250 g) were divided into the following two groups; 7 rats were treated with daily intraperitoneal (i.p.) injection of 0.1% chlorhexidine gluconate (CH) and 15% ethanol solved in 2 ml of saline for 26 days as a control of SP model (CH group) and 6 rats were treated daily with peroral (p.o.) administration of 350 mg/kg of PFD in addition to the daily i.p. injection of aforementioned CH-ethanol-saline solution for 26 days (CH + PFD group). Macroscopic intraperitoneal changes and histological fibrotic changes were graded by scoring in a blind manner. Actual subserosal thickness was measured by observation under light microscope. Body weight gain was significantly greater in CH + PFD group than in CH group (P < 0.05). Macroscopic intraperitoneal adhesion changes in CH + PFD group were significantly fewer than in CH group (P < 0.05). Fibrotic changes were fewer and subserosal thickness in liver and intestine were smaller in CH + PFD group with statistical significance (p < 0.1). We concluded that PFD markedly inhibited or prevented fibrotic changes in the experimental sclerosing peritonitis induced by CH.

Coexistence of Pick bodies and atypical Lewy bodies in the locus ceruleus neurons of Pick's disease

We observed abundant Pick argentophilic inclusion bodies (PBs) as well as some atypical Lewy bodies (LBs) in the locus ceruleus (LC) from a patient with Pick's disease. In addition, there were a few neurons which contained both PBs and LBs. PBs in the LC frequently appeared multiple and had lobulated or irregular shapes, though their ultrastructural elements were the same as those of the PBs appearing in the cerebral cortex, and consisted of randomly arranged smooth-surfaced straight tubules of 15 nm in diameter, mixed with a small number of long-period constricted fibrils. The ultrastructure of the LB coexisting with PB was identical with that previously reported; a dense core was surrounded by concentric layers of radially oriented 10-nm filaments and was clearly distinguishable from the PB. Immunohistochemical examination with various antibodies related to neurofibrillar pathology demonstrated that anti-tau antibodies reacted positively with both PB and the rim portion of LB in the present case; an unusual finding for LB. The anti-neurofilament 200-kDa protein stained only LBs, even when PBs and LBs coexisted in the same neuron. These findings show that two kinds of neuronal fibrillar inclusions, whose underlying cytoskeletal abnormalities are thought to be different, can coexist in the same neuron. In addition, the formation of multiple, lobulated PBs may suggest some particularity of cytoskeletal composition of the LC neurons.

[Measurement of anti-acetylcholine receptor antibody using human rhabdomyosarcoma cell line]

We developed a radioimmunoassay for AChR Ab using AChR solubilized from membrane extracts of human rhabdomyosarcoma cell line (RD cell). The binding affinity of this AChR to the alpha-Bungarotoxin (alpha-BTX) was similar to that of AChR from cell surface. Lyophilized AChR was stable within two months at -20 degrees C. In our assay system, sera from patients with Myasthenia Gravis (MG) showed markedly high titers and frequency (94%) of anti-AChR Ab. On the other hand, almost all sera from normal and non-myasthenic patients such as rheumatoid arthritis and thyroid disease were negative (< 0.2nmol/l). Our assay using AChR from RD cells shows sufficient results in the intra- and inter-CV values, and recovery and dilution tests. AChR Ab titers of our assay showed good correlations with those measured by AChRs from both human ischemic muscles and TE671 cells (commercial kit). The radioimmunoassay for AChR Ab using the membrane extracts of RD cells has high sensitivity, specificity and stability. Therefore, the assay is valuable as the routine assay for the diagnosis of MG.

Continuous and stable recording of the His bundle electrogram during open heart operations

We describe a method for continuously recording the stabilized His bundle electrogram from the aortic root during open heart surgical procedures. This simple technique was useful in all surgical procedures for the oblation of supraventricular tachyarrhythmias in the region around the atrioventricular conduction system.

Clinical evaluation of a new type of centrifugal pump

The major problems with existing centrifugal pumps are leakage, mechanical trauma, and thrombus formation. In consideration of these problems, a new compact centrifugal pump system was developed. The purpose of this study was to evaluate the new centrifugal pump system clinically. Ten patients underwent open heart surgery with a centrifugal pump or a roller pump. During surgery, hemodynamic and hematological data were obtained. A pulsatile assist device in the pump circuit was used in patients with severe heart disease. There was neither operative death nor hospital mortality, and there was no difference with regard to hemodynamic data between the two groups. The centrifugal pump groups, however, had significantly lower hemolysis, especially during prolonged cardiopulmonary bypass. This centrifugal pump could also create sufficient pulsatile flow with a pulsatile assist device. Postoperative macroscopic and microscopic findings demonstrated the smooth surface of the pump without thrombus formation. This centrifugal pump system might be useful for prolonged cardiopulmonary bypass.