[The effect of clomipramine to nocturnal periodic hypoxemia in Duchenne muscular dystrophy]

Respiratory insufficiency is a major cause of death in Duchenne muscular dystrophy (DMD). The earliest sign is a hypoventilation which appears in REM sleep. We administered 20 mg of clomipramine hydrochloride before sleep to two DMD patients with periodic nocturnal hypoxemia. The complaints such as morning headache, nausea and somnolence disappeared promptly. Polysomnography revealed complete suppression of REM sleep and disappearance of periodic hypoxemia in both cases. The most important untoward effect was intractable constipation observed in one patient. Although clomipramine dramatically improved the nocturnal periodic hypoventilation, the therapeutic effects lasted less than three months. Permanent REM sleep suppression is requisite for optimal drug therapy of periodic nocturnal hypoventilation in DMD.

Isolation and partial structure of a unique lipophilic peptide, VAP peptide, from the heads of male silkworm moths

A new lipophilic peptide was isolated from the MeOH-CH2Cl2 extract of adult heads of the male silkworm, Bombyx mori, by monitoring the diapause egg-inducing activity. Partial amino acid sequencing (1-55) revealed this peptide to be a unique type having a high content of lipophilic amino acids, Val, Ala, and Pro, and many repeating sequences. The compound was thus named VAP peptide.

[Imaging and pathological studies on the esophageal dysfunction in patients with myotonic dystrophy]

The purpose of this study is to clarify a correlation between the esophageal dysfunction and suffocation after meals in patients with myotonic dystrophy (MD) and to find how to prevent such accidents. Using imaging methods, we examined eight patients with MD (six of them had difficulty in swallowing), four patients with other neuromuscular diseases (Fukuyama-type congenital muscular dystrophy, congenital myopathy, Machado-Joseph disease, and Duchenne's muscular dystrophy), and two healthy control subjects. We also investigated material from an autopsy of another patient with MD who died of suffocation. In all patients with MD, fluoroscopy and computed tomography showed dilatation of the esophagus, particularly in the proximal third, and residual contrast media in the esophagus 15 to 40 minutes after swallowing. In histologic studies, morphologic changes were confined to the esophageal striated muscle in a patient with MD. These results indicate that regurgitation from the esophagus to the trachea happens more than 40 minutes after swallowing in patients with MD and that histological alterations of striated muscle are primary causes of the esophageal dysfunction. From these findings, we propose that patients with MD should not lie down at least 40 minutes after meals whether they complain of difficulty in swallowing or not.

Cytoplasmic chaperones determine the targeting pathway of precursor proteins to mitochondria

Two ATP-dependent cytosolic chaperones, mitochondrial import stimulation factor (MSF) and hsp70, are known to be involved in the import of precursor proteins into mitochondria. Hsp70 generally recognizes unfolded proteins, while MSF specifically recognizes mitochondrial precursor proteins and targets them to mitochondria in a NEM-sensitive manner. Here we analyzed the relative contribution of these chaperones in the import process and confirmed that the precursor proteins are targeted to mitochondria via two distinct pathways: one requiring MSF and the other requiring hsp70. Both pathways depend on distinct proteinaceous components of the outer mitochondrial membrane. The MSF-dependent pathway is NEM-sensitive and requires the hydrolysis of extra-mitochondrial ATP for the release of MSF from the mitochondrial import receptor, whereas the hsp70-dependent pathway is NEM-sensitive and does not require extra-mitochondrial ATP. The NEM-insensitive, hsp70-dependent import became NEM-sensitive depending on the amount of MSF added. The relative importance of the two pathways appears to be determined by the affinities of MSF and hsp70 for the precursor proteins.

A case of traumatic pseudoaneurysm of the ascending aorta occurring in a postoperative patient who underwent arch replacement and Bentall's operation

A case of traumatic pseudoaneurysm of the ascending aorta occurring in a postoperative patient who underwent an arch replacement and Bentall's operation was reported. A bleeding point was clear at the graft of the ascending aorta, and a pseudoaneurysmal formation was suspected following an echocardiogram. An aortogram demonstrated the presence of an aneurysm approximately 8 cm by 4 cm in size originating 5 cm above the right coronary ostia. An emergency operation was carried out. A Trans-femoral bypass was established before sternotomy. The Operative findings showed that adhesive connective tissue covered a pseudoaneurysm 8 cm by 4 cm in size, and that there was a tear in the anastomosis of the grafts between the ascending aorta and the arch 5 cm above the coronary ostia. Direct suture was performed, using hypothermic circulatory arrest. In this paper, We discuss the mechanism, classification, and operative strategy of traumatic pseudoaneurysm.

Detection of high density lipoprotein binding proteins with a new method using apolipoprotein AI-DNP as a ligand

To detect high density lipoprotein binding proteins, a new ligand blotting method that uses apolipoprotein AI-dinitrophenol as a ligand was established. Apolipoprotein AI-dinitrophenol was prepared by incubating the mixture of apolipoprotein AI and 2,4-dinitrobenzene sulfonic acid sodium salt at pH 8.5. Four to six dinitrophenol groups were found to be conjugated with an apolipoprotein AI molecule without any obvious impairment of its binding activity to the binding proteins. By this detection procedure, we detected two apolipoprotein AI binding proteins in plasma membrane fractions from bovine liver and adrenal cortex with molecular masses of 120 kDa and 95 kDa. Since this new ligand blotting method is simple and time-saving, it is expected to become a useful tool in the studies on high density lipoprotein binding proteins.

[Roll repair of nonconfluent pulmonary artery]

We reviewed the repair of nonconfluent pulmonary artery using a roll to clarify indication of this operation, operative technique (especially the material and the size of conduit) and possibility of total correction. Eleven patients (mean age: five years) and 13 operations including two reoperations were reviewed. The material of the roll was xenopericardium in nine and artificial graft in four operations. No operative death and late death occurred. Five patients required reoperations from three occlusion and two severe stenosis of the roll. Three of nine xenopericardial roll needed reoperations and in two reoperated cases, the roll had been placed behind the aorta. In contrast, one artificial graft needed reoperation. The diameter of the roll was compared with that of normal pulmonary artery estimated from the body surface area. If the roll was too large (more than 125% normal) or too small (less than 100% normal), the luminal diameter of the roll became significantly smaller than appropriate-sized roll (p = 0.002). The size of nonconfluent side of the pulmonary artery also affect the result of repair. In occluded or stenotic cases, the unilateral PA index was significantly smaller than good patent cases (p = 0.014). Total correction was possible in eight cases (73%) including four Rastelli operation, two right ventricular outflow patch enlargement, and two modified Fontan operations without operative death. Thus preoperative evaluation of the pulmonary artery size and anatomy, selection of roll material and size matching seemed to be important for successful roll repair of nonconfluent pulmonary artery.

[Nocturnal hypoxia index: a new pulse oxymetry index of nocturnal hypoventilation in neuromuscular disorders]

Respiratory insufficiency due to progressive muscle wasting is a major cause of death in various neuromuscular disorders. Morning headache and anorexia leading to slowly progressive body weight loss are frequently observed as initial symptoms of insufficient ventilation. From our experience nocturnal pulse oxymetry is a valuable study to detect early respiratory insufficiency and helpful to evaluate the effectiveness of ventilatory assistance, since ventilation is more impaired during sleep in early stage of respiratory insufficiency. Percent desaturation time (total desaturation time (SaO2 < or = 90%)/total sleep time) has been used as the most reasonable index of nocturnal hypoventilation. The criteria for introduction of nocturnal mechanical ventilation is 20% or more in Duchenne muscular dystrophy. Unfortunately, the earliest stage of hypoventilation cannot be detected by this index and it is of no use in advanced respiratory failure, because this index never exceeds 100% by definition. Here we propose a new index for nocturnal hypoventilation, which is defined as follows: nocturnal hypoxia index (NHI) = (% time of 95% > or = SaO2 > 90%) + (% time of 90% > or = SaO2 > 85%) x 2 + (% time of 85% > or = SaO2 > 80%) x 3 + (% time of 80% > or = SaO2 > 75%) x 4 + (% time of 75% > or = SaO2 > 70%) x 5.... This index is good for any stage of respiratory failure, and applicable to nocturnal hypoxia of other causes. The criteria for initiating mechanical ventilation in DMD can be substituted by "NHI is above 130."

[A case of surgical treatment of acute aortic dissection without an intimal tear]

We experienced a case of acute aortic dissection without an intimal tear. A 55-year-old woman with SLE presented with acute chest pain. TEE study showed dissection of the ascending aorta, and accompanied by pericardial effusion. An emergency operation was performed four hours after onset. Intraoperatively, thrombus was encountered in the false lumen of the ascending aorta and the proximal arch. However, intimal tear was not found. She underwent graft replacement of the ascending aorta and the total aortic arch, and had an uneventful postoperative course. Histological examination of a segment of ascending aorta showed no evidence of mucinous degeneration and pathological rupture of the elastic fiber.

Immune response in mice infected with the attenuated Japanese encephalitis vaccine strain SA14-14-2

We characterized protective immune response in mice infected with the attenuated Japanese encephalitis virus (JEV) strain SA(A) derived from the live JE vaccine strain SA14-14-2. In the sera of mice infected with SA(A), antibodies to JEV envelope (E) and non-structural NS1 proteins were detected by Western blot analysis and neutralization, haemagglutination-inhibition (HAI), and complement fixation (CF) antibodies were detected by serological tests. Production of antibody to NS1 protein strongly indicated peripheral growth of SA(A) in mice and its growth induced the immune response. A single immunization with SA(A) significantly protected mice against lethal intracerebral (ic) challenge with the virulent SA(V) strain.

Differences in haemagglutination activity and electrophoretic mobility of E protein between the parent SA14 and attenuated vaccine SA14-14-2 strains of Japanese encephalitis virus

E protein characteristics of the attenuated Japanese encephalitis (JE) virus strain SA(A) derived from the live vaccine strain SA14-14-2 were compared with those of the virulent strain SA(V). SA(A) showed lower haemagglutination (HA) activity with broader optimum pH range of HA reaction than SA(V), and the E protein of SA(A) had slower electrophoretic mobility in sodium dodecyl sulfate-polyacrylamide gel electrophoresis (SDS-PAGE) than that of SA(V). These properties of SA(A) E protein appear to be caused by eight amino acid changes found in the E protein coding region of the SA(A) virus genome.

[A case of sarcoidosis discovered by onset of pneumothorax]

A 24-year-old man was admitted to our hospital with left back and chest pain. A chest X-ray film showed left pneumothorax, bilateral hilar lymphadenopathy, mediastinal widening, and multiple nodular shadows in both lung fields. Chest CT showed a large nodule just under the pleura. High serum ACE and lyzozyme levels, and a noncaseating epithelioid granuloma (revealed by TBLB) led to the diagnosis of sarcoidosis. Steroid therapy was started to prevent a cardiac lesion. Pneumothorax secondary to sarcoidosis in its early stage is rare, and in this case the pneumothorax may have been caused by rupture into pleural space of the largest nodule in the left S9, as a result of necrosis.

[Pericardial effusion following surgery using cardiopulmonary bypass]

Of 156 patients who underwent cardiac or aortic surgery using cardiopulmonary bypass, postoperative pericardial effusion was detected in 89 patients (57%). They were divided into four groups according to the size of pericardial effusion: No effusion (group N, n = 66), small effusion (group S, n = 42), moderate effusion (group M, n = 22) and large effusion (group L, n = 25). In group L, 68% of patients had symptoms and 44% had complications such as subxiphoid drainage and constrictive pericarditis. Fewer patients with perioperative pleurotomy were found in group L than group N (p < 0.05). Postoperative anticoagulation did not affect the size of pericardial effusion. Postoperative amount of drainage were larger in groups, S, M, L than group N (p < 0.05, p < 0.05, p < 0.005). The CRP reelevation rate of each group was equal but the maximum CRP value was higher in group L than group N (p > 0.05). These results suggest that some relationship exists among postoperative drainage, inflammatory response and postoperative pericardial effusion. Since large pericardial effusion is often symptomatic and accompanied by various complications, earlier detection of pericardial effusion and appropriate treatment seems to be essential.

A case of isolated acute DeBakey II redissection occurring in a postoperative survivor who underwent an arch replacement for acute DeBakey IIIb dissection

A case of isolated acute DeBakey II redissection which occurred in a postoperative survivor who underwent an arch replacement for acute DeBakey IIIb dissection is reported. The operative findings revealed that there was an intimal tear above the left coronary cusp, that there was a false lumen in the native ascending aorta, and that a residual false lumen caused by the initial operation had not been detected. Redissection caused mainly by the operative procedure, such as the failure to include the site of the intimal tear in the original repair and the formation of a new dissection as a result of anastomotic failure, is frequently seen. However, isolated redissection is a rare condition. In this paper we discuss classification, diagnosis and treatment of redissection.

Cloning of a gene of the DEAD box protein family which is specifically expressed in germ cells in rats

The cloning of a rat cDNA, RVLG, which encodes a novel protein of 713 amino acid residues with a molecular mass of 77,953, is described. The putative RVLG protein shares amino acid domains that are conserved in the DEAD protein family. It is approximately 52% identical and 85% similar in amino acid sequence to the XVLG1, a product which we previously cloned from Xenopus ovaries, suggesting it is the homologue of XVLG1. The size of the mRNA for RVLG is 3.1kb and can be detected specifically in the gonads of male and female adult rats.

Recognition of mitochondria-targeting signals by a cytosolic import stimulation factor, MSF

MSF, a mitochondrial import stimulation factor purified from rat liver cytosol, is an ATP-dependent precursor protein conformational modulator. As a step toward understanding the specificity of substrate recognition by MSF, various synthetic peptides were examined for their ability to induce MSF ATPase activity. The peptides corresponding to various mitochondria-targeting signal sequences elicited significant ATPase activity. MSF bound the synthetic mitochondrial signal peptides, and ATP hydrolysis caused dissociation of the peptides from MSF. Basic amino acid residues in the signal peptides seemed to be essential for recognition. Thus, MSF is a member of the polypeptide chain-binding protein family with unique recognition specificity and is distinct from the hsp70 family of proteins.

Isolation of a DEAD-family protein gene that encodes a murine homolog of Drosophila vasa and its specific expression in germ cell lineage

In an effort to study the molecular basis of the determination processes of the mammalian germ cell lineage, we have tried to isolate a mouse gene homolog to vasa, which plays an essential role as a maternal determining factor for the formation of Drosophila germ cell precursors. By reverse transcriptase PCRs of mouse primordial germ cell cDNAs using family-specific primers, we obtained a gene (Mvh) encoding a DEAD-family protein that showed a much higher degree of similarity with the product of the Drosophila vasa gene (vas) than previously reported mouse genes. In adult tissues, Mvh transcripts were exclusively detected in testicular germ cells, in which Mvh protein was found to be localized in cytoplasm of spermatocytes and round spermatids including a perinuclear granule. The protein was also expressed in germ cells colonized in embryonic gonads but was not detected in pluripotential embryonic cells such as stem cells and germ cells. These results suggest the possibility that the Mvh protein may play an important role in the determination events of mouse germ cells as in the case of Drosophila vasa.

Compliance with antiplatelet therapy in patients with ischemic cerebrovascular disease. Assessment by platelet aggregation testing

BACKGROUND AND PURPOSE

Antiplatelet therapy is currently one of the methods for preventing transient ischemic attacks and cerebral thrombosis. Because antiplatelet agents are generally administered on a long-term basis, patient compliance is an important factor. The purpose of this study was to determine the compliance of patients during antiplatelet therapy by testing platelet aggregation.

METHODS

To establish the conditions for measuring platelet aggregation, the platelet aggregation test was performed in patients taking 81 mg/d aspirin or 200 mg/d ticlopidine at the following final concentrations of aggregation-inducing agents: 0.5, 1, 2, and 4 mumol/L ADP and 0.5 and 2 micrograms/mL collagen. The optimum measurement conditions for assessing patient compliance were determined. Under the conditions determined in the first study, platelet aggregation was assessed, and the effects of treatment were studied in 159 outpatients and 79 inpatients undergoing antiplatelet therapy. If the antiplatelet effect was insufficient, compliance was checked by interview.

RESULTS

The agents used and the final concentrations found to be optimum for assessing platelet aggregation were 2 micrograms/mL collagen for patients taking aspirin 81 mg/day and 2 mumol/L ADP for patients taking ticlopidine 200 mg/d. In 17 (10%) of the 159 outpatients, platelet aggregation was not adequately reduced because of noncompliance with their antiplatelet therapy.

CONCLUSIONS

This study indicated that monitoring of compliance is important for outpatients on antiplatelet therapy. It is best if platelet aggregation can be checked, but when this is impossible it is necessary to assess compliance periodically and provide patient guidance.

MSF, a novel cytoplasmic chaperone which functions in precursor targeting to mitochondria

Mitochondrial import stimulation factor (MSF) unfolds wheat germ lysate synthesized aggregated mitochondrial precursor proteins and stimulates their mitochondrial import in an ATP dependent manner. Here we analysed the function of MSF mainly by utilizing chemically pure adrenodoxin precursor (pAd). MSF bound to the unfolded pAd and prevented it from losing import competence and also restored the import competence of the aggregated pAd dependent on ATP hydrolysis. The import incompetent aggregated mitochondrial precursors induced the ATPase activity of MSF and the activity was strongly inhibited by isolated mitochondrial outer membrane (OM) but not by trypsin treated outer membrane (tOM). The precursor induced ATPase activity of N-ethylmaleimide (NEM)-treated MSF was not inhibited by OM. In this context, the MSF-precursor complex specifically bound to OM and binding was abolished both by the treatment of OM with trypsin and by the treatment of MSF with NEM. These results show that MSF is a novel cytoplasmic chaperone protein with a mitochondrial precursor-targeting function.

[A case of endobronchial tuberculosis with high serum CA19-9 and SLX level]

A 43-year-old female was admitted to our hospital with mild cough, sputum and right chest pain. The chest X-ray revealed an inhomogeneous shadow in the right upper lung field and mediastinal lymphadenopathy. At first we considered the patient had bronchogenic carcinoma, as her serum CA19-9 and SLX levels were high and the right upper bronchus was obstructed by necrotic tissues. However bronchoscopic specimen showed necrotizing epithelioid cell granulomas and Mycobacterium tuberculosis was detected, and her disease was diagnosed as endobronchial tuberculosis. The case responded well to anti-tuberculosis chemotherapy. The differential diagnosis between bronchogenic carcinoma and endobronchial tuberculosis was very difficult in this case because of high serum level tumor marker and endoscopic findings, which turned to normal after treatment. We discussed the cause of high serum level of CA19-9 and SLX in nonmalignant lung disease.

[A 54-year-old man with generalized muscle atrophy and oculomotor paresis]

We report a 54-year-old man with progressive generalized muscle atrophy and ophthalmoparesis in the terminal stage. He was well until 44 years of age (1982) when he noted weakness in his right hand and muscle atrophy; in May of 1985, he noted weakness in his left hand and in both legs. His weakness had become progressively worse, and he became unable to walk in November of 1985. He noted dysarthria one month later, and dysphagia in March of 1986. His difficulty in swallowing had also become worse; he regurgitated foods into the trachea in September of that year, and he developed a low grade fever on the same day. He was admitted to our service on September 24, 1987. On physical examination, general findings were unremarkable, except for low grade fever (37.3 degrees C). On neurologic examination, he was alert and mentally sound. He had normal vision and visual fields; ocular movements were normal. He had moderate weakness in facial muscles, dysarthria, dysphagia, and atrophy in his tongue. He had marked generalized muscle atrophy with fasciculation. He was unable to stand or walk. His muscle strength was not more than 1/6 in any part. The lower extremities were spastic. Deep reflexes were exaggerated in both lower extremities but were normal in upper extremities. Sensation was intact. Laboratory examination was unremarkable, and so was the cranial CT scan. He was treated with nasogastric feeding. He was able to communicate smoothly using his eyes, but a restriction in the vertical gaze was noted in February of 1989. The range of ocular movement was better in the oculocephalic reflex compared with his spontaneous vertical eye movements. In April of 1990, his horizontal gaze also had become slow, and he was complicated by bronchial asthma. He was treated with 20 mg/day of prednisolone; after the institution of prednisolone, his horizontal eye movement showed much improvement. In the terminal stage, he was able to move his eyes only very slowly; vertical gaze was impossible. His subsequent course was complicated by respiratory tract infection and septicemia, and he expired on July 15, 1992. The patient was discussed in a neurological CPC, and the chief discussant arrived at the conclusion that this patient had amyotrophic lateral sclerosis with oculomotor paresis. Post-mortem examination revealed spongy change involving the posterior column and the posterior spinocerebellar tract, in addition to severe degenerative change in the upper and the lower motoneurons, which were consistent with amyotrophic lateral sclerosis.(ABSTRACT TRUNCATED AT 400 WORDS)

[A case of adenoid cystic carcinoma manifesting Garcin's syndrome--effectiveness of cerebrospinal fluid ferritin as a tumor marker in malignant CNS involvement]

We reported a 69-year-old man exhibiting Garcin's syndrome caused by adenoid cystic carcinoma of the right submandibular gland. The patient first experienced abnormal sensations in his right cheek, and the cranial nerves on his right side gradually became affected. He was admitted for hoarseness and dysphagia. Physical examination revealed a right submandibular mass, and neurological examination revealed that the first cranial nerve and the fifth to twelfth cranial nerves on the right side were affected. Laboratory examination showed a rise of both serum and cerebrospinal fluid (CSF) ferritin, suggesting an intracranial invasion of the submandibular tumor. But other tumor markers, CSF protein and cell counts, CSF pathologic study and radiological studies for the central nervous system (CNS) were all negative. A submandibular tumor biopsy revealed adenoid cystic carcinoma. The radiation therapy, including the skull base, provided relief of the patient's symptoms, the tumor was reduced and serum and CSF ferritin level decreased. It is possible that CSF ferritin is a sensitive marker for CNS involvement of malignant tumor because of its permeability of the blood brain barrier and the absence of correlation between serum and CSF.

[A case report of modified Bentall procedure, aortic arch replacement and mitral valve replacement for a patient with Marfan's syndrome]

A 20-year-old man of Marfan's syndrome who had mitral valve regurgitation, annuloaortic ectasia with aortic valve regurgitation and aortic arch aneurysm was successfully treated with radical operation. Mitral valve replacement was performed with superior wall incision of the left atrium directly. Complete transection of the aortic root made it easy to reach the mitral valve. The diameter of his ascending aorta was 70 mm, and modified Bentall' procedure, Carrel patch method, was performed. Aortic arch was 40 mm in diameter, and total aortic arch replacement was performed under hypothermic circulatory arrest. After the combined operation, patient was recovered uneventfully.