Clinical significance of skin autofluorescence for diabetic macroangiopathy and comparison with conventional markers of atherosclerosis: a cross-sectional and prospective study

Background

Skin autofluorescence (SAF) is a marker for the accumulation of advanced glycation end products (AGEs), and is associated with diabetic macroangiopathy. However, whether SAF is superior to conventional markers of atherosclerosis such as carotid intima-media thickness (IMT) and pulse wave velocity (PWV) in detecting macroangiopathy remains unclear.

Methods

We recruited 845 patients with type 2 diabetes enrolled in a community diabetes cohort (ViNA cohort) who had SAF, IMT, and PWV measured at baseline. The prevalence of macroangiopathy at baseline and new cardiovascular events during the 2-year follow-up period was investigated. SAF was measured using an AGE reader. Coronary artery calcification (CAC) was measured by computed tomography in 485 patients. Peripheral artery disease (PAD) was defined as the ankle-brachial blood pressure ratio of ≤ 0.9.

Results

SAF, IMT, and PWV were significantly correlated with each other, and age, diabetes duration, and estimated glomerular filtration rate were their strong confounders. SAF was associated with baseline stroke and new stroke after adjusting for confounders, but not with coronary artery disease (CAD) or PAD. The nonsignificant relationship between SAF and CAD was consistent with the relationship between SAF and CAC. Multivariate analysis showed a significant association of SAF with baseline and new stroke independent of IMT and PWV. Maximum-IMT was significantly associated with baseline CAD, PAD, and stroke, but not with a new stroke, whereas PWV was associated with a new stroke.

Conclusion

Among diabetic macroangiopathies, SAF is a good stroke biomarker, but not for CAD and PAD.

Supplementary Information

The online version contains supplementary material available at 10.1007/s13340-022-00608-8.

Metabolic Properties of Lowdensity Lipoprotein (LDL) Triglycerides in Patients with Type 2 Diabetes, Comparison with Small Dense LDL-Cholesterol

AIMS

Abnormal compositional changes in low-density lipoprotein (LDL) particles, such as triglyceride (TG) enrichment and size reduction, are common in patients with diabetes. Several cohort studies have demonstrated that LDL-TG and sdLDL-cholesterol (C) are sensitive biomarkers for predicting atherosclerotic cardiovascular diseases beyond LDL-C. Although sdLDL has been extensively studied, little is known about the properties of LDL-TG. We investigated similarities or differences between LDL-TG and sdLDL-C.

METHODS

Fasting plasma was obtained from 1,085 patients with type 2 diabetes who were enrolled in the diabetes regional cohort study (ViNA Cohort). LDL-TG and sdLDL-C concentrations were measured using a homogeneous assay established by us. In a subset of subjects, LDL-TG and sdLDL-C levels were measured postprandially or after treatment with lipid-lowering drugs.

RESULTS

In a quartile analysis, higher LDL-TG quartiles were associated with higher frequency of female and fibrate users, whereas sdLDL-C quartiles were associated with frequency of men, drinking, and metabolic syndrome-related measurements. Higher quartiles of LDL-TG/LDL-C were associated with smoking, drinking, fibrate users, and statin users. LDL-TG was significantly correlated with TG, LDL-C, sdLDL-C, and apolipoprotein (apo) B, with apoB being the primary determinant. LDL-TG correlated to high sensitive C-reactive protein (CRP) independently of other lipids. Mean LDL-TG did not change with fasting/non-fasting. Statin treatment reduced LDL-TG, whereas fibrates increased it, but these drugs reduced sdLDL-C equally.

CONCLUSIONS

LDL-TG levels were more tightly regulated by the number of LDL particles than plasma TG levels were. SdLDL-C was closely associated with metabolic syndrome-related factors, whereas LDL-TG was associated with low-grade systemic inflammation.

Dyslipidemia in diabetic kidney disease classified by proteinuria and renal dysfunction: A cross-sectional study from a regional diabetes cohort

AIMS/INTRODUCTION

Diabetic kidney disease (DKD) exacerbates dyslipidemia and increases the incidence of atherosclerotic cardiovascular disease. DKD is a concept that includes typical diabetic nephropathy and an atypical phenotype without proteinuria. We investigated dyslipidemia in different DKD phenotypes that have not been fully studied.

MATERIALS AND METHODS

Fasting plasma was obtained from 1,073 diabetes patients enrolled in the regional diabetes cohort (ViNA cohort). Non-proteinuric and proteinuric DKD were defined as an estimated glomerular filtration rate <60 mL/min/1.73 m² in the absence or presence of urinary albumin-to-creatinine ratio >300 mg/g. Novel lipid risk factors, low-density lipoprotein (LDL) triglyceride (TG) and small dense LDL cholesterol were measured using our established homologous assay.

RESULTS

The proportion of atherosclerotic cardiovascular disease patients was higher in non-proteinuric DKD and even higher in proteinuric DKD than in non-DKD. Increased estimated glomerular filtration rate grade and albuminuric stage were independently correlated with higher TG, TG-rich lipoprotein cholesterol and apolipoprotein CIII. Therefore, proteinuric DKD had the highest of these levels. Small dense LDL cholesterol and LDL-TG were higher in the proteinuria without renal dysfunction group in the lipid-lowering drug-free subset. Lipoprotein(a) was higher in DKD regardless of proteinuria.

CONCLUSIONS

Proteinuria was associated with an atherogenic subspecies of LDL, whereas renal dysfunction was associated with increased lipoprotein(a). Proteinuria and renal dysfunction independently exacerbated TG-rich lipoprotein-related dyslipidemia. This is in good agreement with the results of large-scale clinical studies in which proteinuria and renal dysfunction synergistically increased the risk of atherosclerotic cardiovascular disease in populations with diabetes.

Myxedema Coma Following the Administration of Gonadotropin-releasing Hormone Agonist Complicated by Acute Pancreatitis

Gonadotropin-releasing hormone (GnRH) agonists have been used for the treatment of various diseases. Although autoimmune thyroid disease has been reported as a rare complication of these agents, the symptoms are almost always transient and non-life-threatening. We herein report a rare case of an 83-year-old man receiving GnRH agonist treatment for prostate cancer who developed myxedema coma complicated by acute pancreatitis. This is the first report of myxedema coma potentially associated with a GnRH agonist. The follow-up of the thyroid function is necessary for patients undergoing treatment with GnRH agonists, especially those known to have or to be susceptible to autoimmune thyroid disease.

Characteristics, outcomes, prognostic factors and treatment of patients with T-cell prolymphocytic leukemia (T-PLL)

Background

T-cell prolymphocytic leukemia (T-PLL) is a rare and aggressive disease. In this study, we report our experience from 119 patients with T-PLL.

Patients and methods

We reviewed the clinico-pathologic records of 119 consecutive patients with T-PLL, who presented to our institution between 1990 and 2016.

Results

One hundred and nineteen patients with T-PLL were analysed. Complex karyotype and aberrations in chromosome 14 were seen in 65% and 52% patients, respectively. Seventy-five patients (63%) were previously untreated and 43 (37%) were initially treated outside our institution. Sixty-three previously untreated patients (84%) received frontline therapies. Overall, 95 patients (80%) have died. Median overall survival (OS) from diagnosis was 19 months [95% confidence interval (CI) 16-26 months]. Using recursive partitioning (RP), we found that patients with hemoglobin < 9.3 g/dl, lactate dehydrogenase (LDH) ≥ 1668 IU/l, white blood cell  ≥ 208 K/l and β2M ≥ 8 mg/l had significantly inferior OS and patients with hemoglobin < 9.3 g/dl had inferior progression-free survival (PFS). In multivariate analysis, we identified that presence of pleural effusion [hazard ratio (HR) 2.08 (95% CI 1.11-3.9); P = 0.02], high LDH (≥ 1668 IU/l) [HR 2.5 (95% CI 1.20-4.24); P < 0.001)], and low hemoglobin (< 9.3 g/dl) [HR 0.33 (95% CI 0.14-0.75); P = 0.008] were associated with shorter OS. Fifty-five previously untreated patients received treatment with an alemtuzumab-based regimen (42 monotherapy and 13 combination with pentostatin). Overall response rate, complete remission rate (CR) for single-agent alemtuzumab and alemtuzumab combined with pentostatin were 83%, 66% and 82%, 73% respectively. In patients who achieved initial CR, stem cell transplantation was not associated with longer PFS and OS.

Conclusion

Outcomes in T-PLL remain poor. Multicenter collaborative effort is required to conduct prospective studies.

Non-occlusive Mesenteric Ischemia with Diabetic Ketoacidosis and Lactic Acidosis Following the Administration of a Sodium Glucose Co-transporter 2 Inhibitor

We herein describe a patient with non-occlusive mesenteric ischemia (NOMI) potentially associated with the administration of a sodium glucose co-transporter 2 (SGLT2) inhibitor. A 60-year-old man with type 1 diabetes was transferred to our hospital due to vomiting and respiratory distress. He was treated with insulin, metformin and a SGLT2 inhibitor, which had recently been added. He was diagnosed with intestinal ischemia complicated by diabetic ketoacidosis and lactic acidosis. Urgent exploratory surgery was performed, and the gangrenous bowel was resected. Histological findings confirmed the diagnosis of NOMI. The administration of SGLT2 inhibitors therefore requires certain exceptions for type 1 diabetes and cautious monitoring for the occurrence of these possible adverse effects.

High-dose imatinib mesylate treatment in patients (Pts) with untreated early chronic phase (CP) chronic myeloid leukemia (CML): 2.5-year follow-up

6535

Background: The standard dose (SD) of imatinib for CP CML is currently 400 mg daily, but higher doses (HD) may be more effective. We conducted 2 consecutive trials using HD imatinib (i.e., 400mg twice daily) in previously untreated early CP CML pts. This is an updated analysis of the longer follow-up. Methods: A total of 175 previously untreated pts received HD imatinib. We compared the results with a previous study using SD imatinib (400mg/day) in untreated pts with early CP CML (N=50). Results: Cytogenetic and molecular responses were evaluable in 222 pts (N=49 at SD, 173 at HD) and 217 pts (N=46 at SD, 171 at HD), respectively. In HD group, Sokal risk classification was good in 69%, intermediate in 29%, and poor in 11% of pts. There were no differences in pre-treatment characteristics between two groups. The median age was 48 years in both groups. Median follow-up is 53 months for SD and 30 months for HD group. Patients treated with HD had a higher rate of complete cytogenetic responses (90% vs 78% with SD, p=0.03) and these occurred earlier, with 69% achieving this response after 6 months of therapy vs 45% with SD (p=0.001). The cumulative incidence of major molecular response was significantly better in HD group (p=0.03), and this response was also observed earlier in HD group: at 12 months 54% in HD and 24% in SD group had achieved this response (p=0.001). At 24 months, 19/70 (27%) evaluable pts with HD versus 3/31 (10%) of pts in SD group achieved complete molecular remission. Four pts (2%) in HD group and 4 pts (8%) in SD group have progressed to advanced phases (p=0.05). There was a trend in favor of the HD group for transformation-free-survival but it was not statistically significant (p=0.07). Overall survival is excellent in both groups (24 month survival, 99% with HD vs 98% with SD; p=0.24). Grade 3 or 4 hematologic toxicity was more frequent in HD group whereas extramedullary toxicity was similar in two groups. The median actual dose in HD group was 800 mg at 12 months, with 39% patients requiring dose reduction at some point. Conclusions: High-dose imatinib provides higher rates of complete cytogenetic responses and earlier molecular responses with some increase myelosupression. The long-term benefit of earlier responses remains to be demonstrated.

[Table: see text]

Distribution of OL-protocadherin protein in correlation with specific neural compartments and local circuits in the postnatal mouse brain

OL-protocadherin (OL-pc) is a cell adhesion molecule that belongs to the cadherin superfamily. A previous study showed that expression of OL-pc mRNA was specific to certain brain nuclei including those of the olfactory and limbic systems, thus suggesting its involvement in neural circuit formation. Here, we examined the distribution of OL-pc protein in the postnatal mouse brain by immunohistochemistry to confirm the possibility of such a role. The results showed that the protein could be mapped to many brain compartments including brain nuclei and higher subdivisions as previously observed for the expression pattern of the mRNA. Sharp boundaries of the distribution were often seen in areas such as the interpedunclar nucleus, cerebellar cortex, and inferior olive. In addition, the protein was detected in some fibers that could not be examined by the previous study using in situ hybridization. For example, prominent staining was noted in the stria medularis, stria terminalis, fasciculus retroflexus, optic tract, and inferior thalamic radiation, structures that seem to connect OL-pc-positive brain regions. These OL-pc-positive brain nuclei and fiber tracts coincide with some local circuits of functional systems such as the olfactory system, nigrostriatal projection, olivo-cerebellar projection, and visual system. These results support the possibility that OL-pc is involved in the formation of specific neural compartments and circuits in the developing brain.

Effects of sugar on vegetative development and floral transition in Arabidopsis

Although sugar has been suggested to promote floral transition in many plant species, growth on high concentrations (5% [w/v]) of sucrose (Suc) significantly delayed flowering time, causing an increase in the number of leaves at the time of flowering in Arabidopsis. The effect of high concentrations of Suc seemed to be metabolic rather than osmotic. The delay of floral transition was due to extension of the late vegetative phase, which resulted in a delayed activation of LFY expression. In addition, growth on low concentrations (1% [w/v]) of Suc slightly inhibited flowering in wild-type plants. This delay resulted from effects on the early vegetative phase. This inhibition was more pronounced in tfl1, an early flowering mutant, than in the wild type. Although 1% (w/v) Suc was reported to promote floral transition of late-flowering mutants such as co, fca, and gi, floral transition in these mutants was delayed by a further increase in Suc concentration. These results suggest that sugar may affect floral transition by activating or inhibiting genes that act to control floral transition, depending on the concentration of sugars, the genetic background of the plants, and when the sugar is introduced. Growth on 1% (w/v) Suc did not restore the reduced expression levels of FT and SOC1/AGL20 in co or fca mutants. Rather, expression of FT and SOC1/AGL20 was repressed by 1% (w/v) Suc in wild-type background. The possible effects of sugar on gene expression to promote floral transition are discussed.

L-arginine immunoreactive enteric glial cells in the enteric nervous system of rat ileum

L-arginine is a precursor of nitric oxide (NO) that may be involved in neuronal activity in the gastrointestinal tract. It is known that NO is formed from L-arginine by NO synthase which is localized in neurons in the enteric nervous system. The present study demonstrated that significant L-arginine immunoreactivity was present in the enteric ganglia. Ultrastructural examination showed that L-arginine immunoreactivity was present in the ganglionic glial cells but not in neurons. These findings suggest that enteric glial cells may represent the main reservoir of L-arginine, which may possibly be transferred to neurons when used.

Citrulline immunohistochemistry for demonstration of NOS activity in vivo and in vitro

Nitric oxide (NO), a biomolecule with major cytotoxic potency, is generated by NO synthases (NOS) utilizing l-arginine as substrate and citrulline is formed as a "side product." In brain tissue, citrulline is considered to be produced exclusively by NOS, due to the incomplete urea cycle in the brain. We aimed to characterize NOS activity by citrulline immunostaining in different cell types of the brain under in situ conditions and in slice and culture experiments. NOS-positive neurons and activated microglial cells were the most prominent citrulline-positive structures. Lack of citrulline immunoreaction in neurons of nNOS knockout mice emphasizes the dependency of citrulline positivity on NOS activity, and likewise there was no citrulline staining after application of the NOS inhibitors 7-nitroindazole and NIL. Interestingly, only a portion of NOS-containing neurons costained for citrulline. The inhibition of argininosuccinate synthetase by alpha-methyl-dl-aspartate increased the number of citrulline-positive cells, apparently due to reduction of the turnover rate of citrulline. Cells positive for NOS but negative for citrulline may indicate that the enzyme is either not activated or inhibited by cellular control mechanisms. The fact that not all citrulline-positive cells were NOS positive may be explained by an insufficient detection sensitivity or by disparate sites of citrulline production and recycling. The present results show that citrulline immunocytochemistry offers a viable and convenient means for studying NOS activity at the single-cell level to elicit its posttranslational control under physiological and pathophysiological conditions.

Fields of nonlinear cladding optical waveguides excited by butt-coupled linear waveguides at medium power levels

The evolution of medium power fields of nonlinear optical waveguides is investigated numerically. The analysis method is based on mode matching of local normal modes of bounded waveguides. Nonlinear cladding waveguides are butt-coupled to linear waveguides. The path of a medium power level beam winds between the film and the nonlinear cladding. The input beam travels toward the nonlinear modal field, at which point the beam is not stationary. After the beam passes the location, it is forced to turn back. The lateral shift of an incident waveguide affects the path of a beam. Saturation and linear absorption lessens the oscillation of a winding path.

Methylation status of the p15INK4B gene in hematopoietic progenitors and peripheral blood cells in myelodysplastic syndromes

We previously reported that the hypermethylation of the p15INK4B gene promoter was frequently observed in myelodysplastic syndromes (MDS), and that it may be associated with disease progression. An unanswered question is whether p15INK4B gene methylation is restricted to undifferentiated blastic cells, or whether differentiated cells such as granulocytes or erythrocytes of MDS origin also harbor this epigenetic alteration. In this study, we analyzed the methylation status of the p15INK4B gene in MDS by the methylation-specific PCR (MSP) method, which is more sensitive than Southern blotting. The bone marrow mononuclear cells (BM-MNCs) of 23 MDS patients were analyzed, and six of them showed p15INK4B methylation. Progenitor assay with methylcellulose medium was also performed in all patients. In two of the six patients with p15INK4B-methylated BM-MNCs, erythroid and/or non-erythroid colonies formed were subjected to molecular analysis. Colonies with and without p15INK4B methylation were detected in both patients. Furthermore, X-chromosome inactivation (XCI) pattern of each colony was simultaneously determined by MSP-based human androgen receptor gene analysis (HUMARA-MSP), and all p15INK4B-methylated colonies showed the same XCI pattern, which was dominant among the colonies, while p15INK4B-unmethylated colonies showed both patterns of XCI, in each of the two patients. We then examined the methylation status of the p15INK4B gene of granulocyte (PB-PMN) fractions from 10 patients with available peripheral blood cells. In all four patients with p15INK4B-methylated BM-MNCs, their PB-PMNs showed p15INK4B methylation. These results suggest that p15INK4B methylation in hematopoietic cells in MDS patients is restricted to the MDS clone but not necessarily to blast cells.

Clonality analysis by methylation-specific PCR for the human androgen-receptor gene (HUMARA-MSP)

The human androgen-receptor gene (HUMARA) has been used for analysis of X chromosome inactivation (XCI) pattern because of a polymorphic short tandem repeat (STR) near the 5'-promoter region correlated with XCI. We introduce a novel method to analyze XCI pattern, named HUMARA methylation-specific PCR (HUMARA-MSP) assay, which analyzes methylation status of the HUMARA gene by bisulfite modification instead of a methylation-sensitive restriction enzyme. Although the original MSP method shows whether there is a methylated band or not, our HUMARA-MSP method identifies the patterns of methylated and unmethylated bands. Because this method identifies either unmethylated or methylated alleles in each PCR tube and shows opposite band patterns dependent on methylation status, we can assess the XCI pattern independently twice. This method can avoid false results by incomplete enzyme digestion and incomplete bisulfite modification will not affect the results. Extremely small quantities of samples, such as hematopoietic colonies, were also available for HUMARA-MSP assay. Because DNA modified by sodium bisulfite is also available for assessment of methylation status of other genes by setting specific primers for them, we performed the simultaneous assessment of clonality and aberrant hypermethylation of p15INK4B gene in myelodysplastic syndromes. These simultaneous assessments were easily possible and provided much information despite requiring only a small volume of DNA. The HUMARA-MSP assay may facilitate the analyses for pathogenesis of hematological disorders because of its simplicity, sensitivity and wide applicability. Leukemia (2000) 14, 207-212.

Inhibitory effect of electroacupuncture on murine collagen arthritis and its possible mechanisms

The influence of electroacupuncture (EA), a traditional Chinese medical treatment, on type II collagen-induced arthritis (CIA) was examined in DBA/IJ mice in vivo. Mice were immunized intradermally twice at a 3-week interval with bovine type II collagen (C II). EA stimulation, begun on day 21 simultaneously with the second immunization, was applied at the acupoint equivalent to GV4 three times a week for 3 weeks. The results showed that EA delayed the onset, attenuated the severity of arthritis, and reduced the anti-collagen antibody level. Furthermore, we investigated the impact of EA on the productions of endogenous interleukin-1 beta (IL-1 beta) and prostaglandin E2 (PGE2), and the levels of IL-1 beta mRNA in splenocytes and synovial tissues from C II immunized mice on day 45 and cyclooxygenase-2 (COX-2) mRNA in lipopolysaccharide (LPS)-stimulated macrophages of normal mice by using reverse transcriptase-polymerase chain reaction (RT-PCR). EA stimulation significantly inhibited the concentrations of splenic endogenous IL-1 beta and serum PGE2. The expression of IL-1 beta mRNA in spleen cells was obviously down-regulated and that in synovial tissues was modestly affected by EA. COX-2 mRNA was highly expressed in cultured peritoneal macrophages when stimulated with LPS. Previous treatment with EA also reduced LPS-stimulated induction of COX-2 mRNA. These data suggest that EA has an inhibitory effect on murine CIA, and the partial mechanism of its therapeutic result may be attributed to inhibiting the productions of IL-1 beta and PGE2 by suppressing the IL-beta and COX-2 gene activations.

DNA replication in the 1-cell mouse embryo: stimulatory effect of histone acetylation

Temporal and spatial distribution of the sites of DNA replication were examined in 1-cell mouse embryos. Embryos were labelled with bromodeoxyuridine (BrdU) at hourly intervals after fertilisation, and the incorporation of BrdU was examined by laser-scanning confocal microscopy following immunostaining with an anti-BrdU antibody. DNA replication first started uniformly in both the male and female pronuclei in the intranuclear region and then was observed in the peripheral regions of nucleus and nucleolus. These changes, however, occurred asynchronously in that the female pronucleus required a longer time to complete replication in the intranuclear region but not in the peripheral regions. Inhibiting transcription with alpha-amanitin had no effect on the temporal and spatial patterns of DNA replication. Treatment of the embryos with trapoxin, a specific inhibitor of histone deacetylase, accelerated the completion of replication in the peripheral regions but not in the intranuclear region. These results suggest that DNA replication is temporally and spatially regulated in the 1-cell embryos and that acetylation of histones, but not transcription, is involved in the regulation of DNA replication.

Isolation and identification of metallothionein isoforms (MT-1 and MT-2) in the rat testis

It has been a long-lasting controversial issue as to whether or not the male genital organs, such as the testis and prostate, contain metallothioneins (MTs), a group of cysteine-rich heavy-metal-binding proteins that play a role in detoxifying heavy metals such as cadmium (Cd). Earlier studies reported that the rodent testis lacks MTs and concluded that this is why the testis is very susceptible to Cd, although other indirect experimental evidence suggests that MTs are present in this organ. A deficiency of MTs in the testis was originally suspected on the basis of amino acid composition analysis, since MT-like proteins isolated as Cd-binding proteins did not have a characteristic MT structure. In the present study, we demonstrate that the rat testis indeed expresses Cd-binding proteins with sequences identical to those previously described for MT-1 and MT-2, the major isoforms. To confirm that MT-1 and MT-2 are present in the rat testis, we purified and isolated Cd-binding proteins by homogenization using Cd-containing buffer, followed by sequential purification using Sephadex G-75 gel filtration chromatography and anion HPLC column chromatography, which yielded Cd-binding protein-1 (Cd-BP-1) and -2 (Cd-BP-2). After pyridylethylation, Cd-BP-1 and Cd-BP-2 were subjected to specific protein fragmentation by acids and endopeptidases, which revealed that these Cd-binding proteins have the same primary structures as MT-1 and MT-2 respectively. Thus we believe that the present results clearly resolve the long-standing debate about the presence of MTs in the testis, at least in the rodent.

Influence of moxibustion on collagen-induced arthritis in mice

The influence of moxibustion, a traditional Chinese medical treatment; on type II collagen-induced arthritis (CIA) was examined in DBA/1J mice in vivo. Mice were immunized intradermally twice at 3-week intervals with bovine type II collagen (C II). The main incidence of arthritis started around day 30 and lasted to day 60 after the first immunization. Moxibustion, using three different regimens, was applied at the acupoint equivalent to GV4 every other day. Moxibustion, from day 0 to day 30 after the first immunization, suppressed the onset and development of arthritis, as well as anti-collagen antibody level. Treatment with moxibustion, from the day 31 to day 60, also resulted in a significant inhibition of progression of arthritis and production of anti-C II antibody. Furtherfore we examined the influence of moxibustion on the established arthritis. Moxibustion given from day 61 to day 120, mildly but significantly decreased the anti-C II antibody level in diseased mice, while the bone erosion and joint destruction were not affected. These results indicate that moxibustion could prevent the incidence and attenuates the development of murine CIA.

[Aortic arch replacement performed in emergency in a short-term after grafting for abdominal aortic aneurysm]

Two cases of successful staged replacement of multiple aortic aneurysms are reported. Case 1: A 65-year-old man was found to have abdominal aortic and aortic arch aneurysms. He underwent abdominal aneurysmectomy and Y-grafting in the first stage. A month after his discharge, he was transferred to our hospital because of abrupt chest pain. Two days later, he fell into shock and emergent aortic arch replacement was performed successfully. Case 2: A 46-year-old man was transferred to our hospital because of abrupt abdominal pain and shock. CT scan revealed the rupture of the abdominal aneurysm. He received emergent abdominal aneurysmectomy and Y-grafting successfully. Three months later, he was readmitted because of back pain. CT scan revealed DeBakey Type I dissecting aneurysm. After three days, PaO2 of blood gas analysis fell to 46 mmHg, and absent femoral pulsation and oliguria were also observed. Therefore, aortic arch replacement was performed in emergency. The intimal tear was found in the distal aortic arch. The both of cases are doing well 24 months and 10 months after surgery respectively. It is important to scrutinize the order of surgery for multiple aortic aneurysms and to control blood pressure properly after aneurysmectomy.

Closure of a ventricular septal defect in a patient with von Willebrand disease

Few reports of open heart surgery being performed in patients with von Willebrand disease (vWD) have been documented. We describe herein the case of a 5-year-old girl with a ventricular septal defect (VSD) and vWD who underwent patch closure under cardiopulmonary bypass (CPB). The hematological parameters relating to vWD, namely, factor VIII, von Willebrand factor, and factor VIII-related antigen were monitored perioperatively. These laboratory findings were elevated after the termination of CPB, and consistently maintained within the normal range for 4 months postoperatively. The operation was successfully completed without the administration of factor VIII concentrates or homologous blood products.

[Quantification of brain perfusion SPECT with N-isopropyl-p-iodoamphetamine using noninvasive microsphere method: estimation of arterial input by dynamic imaging]

We have developed a noninvasive method to quantify brain perfusion SPECT with 123I-N-isopropyl-p-iodoamphetamine (IMP) using serial dynamic planar imaging of the initial transit phase. The method is based on the microsphere model, but does not require arterial sampling. Serial dynamic planar imaging was performed for 6 min after the bolus injection of IMP (167 MBq in 1.5 ml), followed by additional planar imaging at 20 min and SPECT scan thereafter. The total arterial input to the brain during the initial 5 min after injection was estimated by the injected dose, with the correction of the lung retention, divided by cardiac output (CO). CO was estimated from the initial transit of IMP in the right heart. Cardiac output index (COI), obtained from the integral of the first transit of IMP in the right heart divided by the injected dose, was calibrated by CO measured by Doppler ultrasonography. Regional cerebral blood flow (rCBF) obtained by this method in normal subjects was acceptable. However, the results may be influenced by the injection technique, and careful attention should be considered for clinical application of this method.

Immunohistochemical localization of arginine and citrulline in rat renal tissue

Using antibodies highly specific for L-arginine and L-citrulline, we localized these amino acids in rat kidney with immunohistochemical methods. Highest levels of arginine immunoreactivity were observed in epithelial cells of proximal tubules in the outer stripe of the outer medulla and the collecting ducts in the cortex. Staining intensity of proximal convoluted tubules in the outer stripe decreased from the inner side to the outer side. In the inner medulla, collecting ducts were labeled with moderate intensity. Staining within the cortex was apparent only with collecting ducts. Citrulline immunoreactivity was localized in the epithelial cells of collecting ducts both in the cortex and medulla. Immunoreactivity was also found in glomerular podocytes and in the epithelial cells of proximal convoluted tubules in the outer medulla. These localizations were different from those of other amino acids previously reported. The precise cellular distribution of arginine and citrulline in rat kidney was determined for the first time by an immunohistochemical method in the present study.

Septal perfusion and wall thickening in patients with left bundle branch block assessed by technetium-99m-sestamibi gated tomography

Septal hypoperfusion is often observed in patients with complete left bundle branch block (LBBB) in myocardial perfusion imaging. Abnormal wall motion in the septal region may potentially cause artifactual perfusion abnormalities. To assess the effect of abnormal wall thickening on myocardial perfusion images, ECG-gated sestamibi SPECT was performed on 12 patients with LBBB and 10 normal subjects used as controls.

METHODS

After administration of 740 MBq 99mTc-sestamibi injection at rest, ECG-gated SPECT was obtained 60 min later with division of the cardiac cycle into eight frames.

RESULTS

Septal hypoperfusion was noted in 10 patients on nongated images and 11 patients on end-systolic (ES) images, whereas only two patients showed abnormalities on end-diastolic (ED) images. The septal to lateral wall count ratio in the LBBB group was lower (0.72 +/- 0.09) than in the control group (0.84 +/- 0.09) (p < 0.01) at nongated images, while it was similar at ED images (0.84 +/- 0.11 versus 0.86 +/- 0.12; ns). In addition, the count increase from ED to ES during a cardiac cycle in the septal region was smaller compared with the lateral region in the LBBB patients (25% +/- 19% in the septal region, versus 48% +/- 14% in the lateral region; p < 0.01), indicating less wall thickening in the septal region.

CONCLUSION

Smaller count increase due to reduced wall thickening in the septal region may mimic hypoperfusion in patients with LBBB. This artifact can be eliminated with ECG-gated 99mTc-sestamibi SPECT, particularly with ED images.

[Ascending aortic aneurysms operated through redo median sternotomy under selective cerebral perfusion]

Case 1: A 34-year-old man who had received ventricular septal closure at 4 years old was found to suffer from annuloaortic ectasia with severe aortic regurgitation and giant ascending aortic aneurysm accompanying with dissection. Median sternotomy was performed under selective cerebral perfusion to control bleeding when the aorta was injured. He was successfully replaced the ascending aorta and the aortic valve with the composite graft including an aortic prosthetic valve by modified Piehler's procedure. Case 2: A 44-year-old man received mitral valve replacement and tricuspid annuloplasty due to mitral regurgitation with tricuspid regurgitation. After surgery, he suffered from mediastinitis. Three months later, he was found to have pseudoaneurysm of the ascending aorta. During the sternotomy done under selective cerebral perfusion, the pseudoaneurysm was injured but bleeding was controlled easily. The defect of the aorta was closed successfully using a Dacron patch and covered with the right sternocleidomastoid muscle flap. Sternotomy under selective cerebral perfusion is very useful and safe for such patients as to have risks to injure the aorta or the heart during the sternotomy.

Spontaneous hemopneumothorax

BACKGROUND

Spontaneous hemopneumothorax is a rare disorder, occurring in 1% to 12% of patients with spontaneous pneumothorax. We studied our previously treated patients to determine the nature of optimal operative management.

METHODS

This was a retrospective case study. From 1987 to 1994, of 428 cases of spontaneous pneumothorax that occurred in 234 patients treated at our institution, hemopneumothorax developed in 10 patients (2.3%). The clinical features of these patients were studied.

RESULTS

The amount of bleeding ranged from 600 to 1,600 mL, and 3 patients exhibited symptoms of shock, such as sweating, nausea, and syncope. Six patients underwent operation within 7 days from the onset, and this involved resection of the bullae or pneumorrhaphy, or both. The source of bleeding was identified in 5 patients. Pathologic examination showed marked fibrosis with alcian blue-positive deposits of aberrant vessels. All 6 patients continue to be well postoperatively without recurrence or complications. Four patients did not undergo early thoracotomy. However, decortication was required in 3 of these patients because of a reactive fluid collection in the pleural space, which led to impaired lung expansion.

CONCLUSIONS

Early surgical repair should be considered once diagnosis of a spontaneous hemopneumothorax is confirmed, because this provides better long-term results. Video-assisted thoracoscopic surgery as well as minithoracotomy should be considered as surgical options because of the improved quality of life they confer.

[Value of stress-rest ECG gated SPECT one day protocol using 99mTc-MIBI]

A total of 110 patients suspected with CAD who had symptoms or ECG abnormalities were enrolled in the stress-rest ECG gated SPECT one day protocol using 99mTc-MIBI. All the patients underwent symptom-limited exercise testing and 250 MBq of MIBI was injected at peak exercise. Exercise perfusion SPECT images were reviewed by two trained doctors to classify into three groups; normal, equivocal and abnormal. Patients with normal stress image (n = 53) did not receive the resting study. On the other hand, those with equivocal (n = 20) and abnormal (n = 37) stress images performed resting study, including gated SPECT. Of 20 equivocal cases, 16 patients showed unchanged resting perfusion. All of these had normal wall motion. The remaining 4 patients showed improved resting perfusion, indicating presence of myocardial ischemia. Of 37 abnormal cases, 12 patients showed improved resting perfusion, whereas 25 patients showed unchanged resting perfusion. Cardiac events were more often observed in abnormal cases, especially those associated with myocardial ischemia, while good prognosis was obtained in normal cases. Values of this protocol are (1) Patients with normal stress images need no resting study. (2) All the procedure can be completed in one day. (3) Both cardiac function and perfusion can be obtained with gated SPECT. These data indicates that this protocol is valuable for screening patients suspected with CAD.

Axonal swellings in cerebellar white matter of groggy mutant rat

In the groggy mutant rat, a number of axonal swellings appeared in the cerebellar white matter from 180 days of age onward. Since these axonal swellings were immunostained with an antibody against calbindin D28k, the axons forming these swellings were considered to belong to Purkinje cells. They were also immunostained with an anti-neurofilament antibody, and ultrastructurally characterized by the presence of myelin sheaths around them and abnormal accumulations of filamentous structures, mitochondria and smooth endoplasmic reticula (SER) in their axoplasm. The SER were considered to convey acid phosphatase (ACPase) to the swelling's axoplasm, where ACPase was set free from the SER throughout the axoplasm and engaged in the digestion of cytoplasmic organelles. The groggy rat is useful model model for the study of the mechanism of the age-related formation of axonal swellings.

Evaluation of surgical risk in preoperative biliary drainage patients by blood chemistry laboratory data--with special reference to rate of reduction of serum bilirubin levels

BACKGROUND/AIM

In Japan, it is generally accepted that biliary decompression should be performed before surgical operations on patients with obstructive jaundice. However, even when adequate decompression and effective reduction of serum bilirubin levels are achieved before surgical operations, it is not uncommon for unforeseen postoperative complications to occur. In this study, we analyzed the effectiveness of biliary drainage prior to pancreatoduodenectomy in patients with malignant obstruction of the papilla of Vater clinically manifested by obstructive jaundice.

PATIENTS AND METHODS

We retrospectively examined the serial blood chemistry laboratory data of 44 patients with periampullary carcinoma who had preoperative obstructive jaundice and underwent pancreatoduodenectomy during the last 10 years. We divided the cases into three groups according to the rate of decrease in serum bilirubin levels, "b": group I, b <-0.09; group II, -0.09<b<-0.05; and group III, -0.05<b. There were no significant differences between the three groups in regard to sex, location of tumor and method of biliary decompression, however, there was significantly higher morbidity rate in group III.

RESULTS

The level of biliary enzymes (gamma-GTP, ALP) tended to be higher in group I and lower in group III. Although TB and DB decreased to below 5 mg/dl before pancreatoduodenectomy in all three groups, transaminase levels instead rose in group III just before pancreatoduodenectomy.

CONCLUSION

This suggested that liver damage continued to progress after biliary decompression when the reduction rate was low, and thus we should carefully monitor such patients for postoperative complications.

Concentric lamellar bodies in axon terminals and preterminal axons of cerebellar Purkinje cells in groggy mutant rat: acid phosphatase cytochemistry

The process of formation and degeneration of concentric lamellar bodies (CLBs) in axon terminals and preterminal axons of Purkinje cells were examined by acid phosphatase (ACPase) cytochemistry. In myelinated axons, tubular structures measuring 20-50 nm in diameter contained ACPase reaction products. In altered axon terminals and preterminal axons of Purkinje cells, elongated saccular structures contained numerous reaction products. These saccular structures were arranged concentrically and enclosed cytoplasmic organelles. In the CLBs displaying degenerative profiles, ACPase reaction products were dispersed in the degenerating materials. The nature of the tubular structures and their roles in the transport of ACPase and the formation of CLBs are discussed.

[Assessment of 201Tl myocardial SPECT reinjected at 24 hours after stress imaging]

To improve the quality of 24 hours delayed images (24 DL) of stress thallium-201 myocardial SPECT, reinjection was performed at 24 hours later (24 RI), and the results were compared with those of 24 DL. A total of 45 patients were studied, including 18 patients in 24 DL, 27 patients in 24 RI. All of them showed persistent defect or incomplete redistribution on the routine stress and 3 hours delayed SPECT scans. In 24 RI, 37 MBq of thallium-201 was reinjected at 24 hours later. Myocardial count of 24 DL was about 1/4 of stress image, while 24 RI was about 1/2. Quality of 24 RI image was nearly equal to 3 hours delayed image. Of regions without redistribution at 3 hours delayed image, 5 (36%) regions showed new redistribution at 24 RI. Of regions incomplete redistribution, 6 (25%) regions showed further redistribution. Compared with 24 DL, the frequency of redistribution tended to be higher in this protocol than that of the 24 DL (11%, 17% respectively). In conclusion, the reinjection at 24 hours delayed imaging was considered to be useful to evaluate viability of myocardium in patient with CAD.

[Thoracoscopic treatment of a giant bulla: a case report]

A 38-year-old man was admitted to our hospital because of left giant bulla and pneumothorax. His chest X-rays and CT scan showed giant bulla of the left upper lobe and left pneumothorax. We performed bullectomy using the ENDOPATH ENDO LINEAR CUTTER 60 mm and 35 mm disporsable surgical stapler under thoracoscopic guidance. Clipping with end-clips and fibrin glue were effective for miner air leakage. There were no complications such as prolonged air leakage or incomplete lung re-expansion. His post operative couse was uneventful and he was discharged from the hospital on the 11th post operative day. When performed along with mini-thoracotomy, thoracoscopic operation is useful in treating patients with giant bulla.

[Assessment of left ventricular count increase with ECG-gated 99mTc-MIBI SPECT using a single-head rotating gamma-camera]

ECG-gated 99mTc-MIBI SPECT was performed in 33 patients, including 17 normal subjects and 16 patients with old myocardial infarction. To compare the findings by echocardiography (UCG), regional wall motion was qualitatively assessed by cine-mode display and quantitatively measured as an increase in regional count from end-diastole to end-systole. The percent count increase and relative count increase was measured to display on the Bull's eye polar map. In the study of normal subjects, the count increase was greater in apical regions and smaller in septal regions. Regional wall motion by this method correlated well with UCG findings (agreement: 97%, complete agreement: 60%). A mild but significant correlation was observed between the count increase by this method and the percent wall thickening by UCG. We conclude that regional wall motion can be accurately evaluated with ECG-gated 99mTc-MIBI SPECT, which thus permits simultaneous assessment of regional wall motion and myocardial perfusion.

Age-related and region-specific increase in number of concentric lamellar bodies in axon terminals and presynaptic axons in central nervous system of groggy mutant rat

In some regions of the central nervous system (CNS) of the groggy rat, a mutant with a movement disorder, concentric lamellar bodies (CLBs) were formed in numerous axon terminals and presynaptic axons. These bodies were counted electron microscopically in the lateral cerebellar nuclei of Slc:Wistar and groggy mutant rats at 20 to 180 days of age. In the Slc:Wistar rat groups, the mean numbers of axonal CLBs were mostly under 1.0 per 100 microns2, except for the 30-day-old rat group which showed a value of 1.7. In the groggy rat groups, the numbers of axonal CLBs greatly increased from 40 days of age onward, reaching the maximum mean number of 23.7 per 100 microns2 in the 90-day-old rat group and subsequently decreasing; however, significant numbers were still present in the 180-day-old rat group. Since these bodies have been reported to contain an acid phosphatase (ACPase), the regional specificity of their appearance in the CNS was examined by light and electron microscopic ACPase histochemistry. In the 90- and 180-day-old groggy rats, numerous particulate deposits of ACPase reaction products were found in the neuropil of the lateral, interposed and medial cerebellar nuclei, the superior, lateral and spinal vestibular nuclei, and the spinal gracile nuclei. By electron microscopy, the particulate deposits in the cerebellar and vestibular nuclei were confirmed as the CLBs in axon terminals, while those in the gracile nuclei were revealed to be the dystrophic axons. Thus, it was suggested that the axon terminals and presynaptic axons, having a high capacity to form the CLBs in the groggy rats from 40 days of age onward, belong to the Purkinje cells.

An immunohistochemical study of aspartate, glutamate, and taurine in rat kidney

Biochemical studies have revealed considerable amounts of free amino acids in the kidney. We examined the intrarenal distribution of three amino acids (aspartate, glutamate, and taurine) in the rat kidney with an immunoperoxidase method. In the renal cortex, all three amino acids were concentrated in the renal corpuscles and in the epithelia of the collecting tubules. Immunostaining of the collecting tubules was more intense in the principal cells than in the intercalated cells. The distal convoluted tubules were also immunostained with aspartate- and glutamate- specific antibodies but not with the taurine-specific antibody. In the renal medulla, the immunoreactivity specific for aspartate and for glutamate was similar; it was weak in the thick portion of the loop of Henle and strong in the collecting tubules. Immunoreactivity specific for taurine was restricted to regions within the epithelia of the thin portion of the loop of Henle and the collecting tubules. The significance of the accumulated amino acids as osmoregulatory agents is discussed.

Electron microscopic cytochemistry of acid phosphatase activity in dystrophic axons of rat gracile nuclei

Dystrophic axons (DAs) in rat gracile nuclei were largely classified into two types. One type had a focal swelling measuring about 2-8 microns in diameter, and contained greatly increased numbers of various cellular organelles. Numerous reaction products of acid phosphatase (ACPase) cytochemistry were deposited in the cytoplasmic matrix and the multilaminated bodies. The second type ranged from 8 microns to 50 microns in diameter, and was characterized by the presence of a large number of fine tubular structures in the cytoplasm. Only a few reaction products of ACPase cytochemistry were localized in the small vesicular structures. The functional role of ACPase in the degradation and accumulation of cellular organelles in DAs is discussed.

The successful surgical repair of a traumatic transection of the descending thoracic aorta: report of a case

An 18-year-old man involved in a traffic accident presented with a left-sided hemothorax. After undergoing left chest tube drainage, he showed temporary stable hemodynamics for 7 h. Later, an emergency left thoracotomy was performed because of abrupt hemorrhagic shock. The intima and media of the descending thoracic aorta was completely transected, and a tube graft was successfully interposed with a simple aortic clamp in 47 min. The patient was eventually discharged from the hospital with no sequelae, such as paraplegia.

Localization of nitric oxide-related substances in the peripheral nervous tissues

Nitric oxide (NO) is now recognized as a transduction molecule in many biological systems, and is known to promote the synthesis of cGMP by activating the soluble guanylate cyclase. NO synthase which fully accounts for all the neuronal activity of NADPH diaphorase catalyzes L-arginine to NO and L-citrulline. In the present study, the localization of NO-related substances, L-arginine, NO synthase, L-citrulline and cGMP in the enteric plexus and dorsal root ganglia was demonstrated with immuno- or enzyme-histochemical methods. L-Arginine was proved accumulated in glial cells, while NO synthase and L-citrulline were found in neurons. Cyclic GMP was predominantly observed in glial cells. These results reveal L-arginine-NO-cGMP pathway may be present in the enteric plexus and dorsal root ganglion as in the brain, and provide visible evidence that NO mediates neuron-glia communications in this pathway.

A patient with hepatocellular carcinoma who underwent resection of the primary lesion 10 years ago and resection of a giant adrenal metastasis 8 and a half years later

A 56-year-old male consulted us because of a palpable mass and pain of the left flank 8 and a half years after resection of hepatocellular carcinoma of the left lobe about 3 cm in diameter. Ultrasound examination of the abdomen demonstrated a tumor about 10 cm in diameter showing a mosaic of hyperechoic and hypoechoic areas on the upper pole of the left kidney. By angiography, the tumor was found to be supplied mainly by the inferior adrenal artery. PIVKA-II was increased. Adrenal metastasis of hepatocellular carcinoma was suspected, and adrenalectomy was carried out. No intrahepatic metastasis was noted. The tumor was histopathologically identified as a pseudo-glandular type of moderately differentiated hepatocellular carcinoma with a trabecular pattern similar to the primary lesion. In this patient, a resectable giant metastasis was observed only in the left adrenal gland and no intrahepatic metastasis was demonstrated 8 and a half years after resection of hepatocellular carcinoma. The patient has survived 10 years after the first operation. This case is considered to be important for evaluation of the treatment for distant metastasis of hepatocellular carcinoma.

Evidence for the presence of L-arginine in the glial components of the peripheral nervous system

L-Arginine is a precursor of nitric oxide that has been identified as an endogenous activator of soluble guanylate cyclase. We have recently reported the immunocytochemical localization of free L-arginine in glial cells in the central nervous system (CNS) using specific anti-arginine antibody. In the present study, we focused our attention on this particular amino acid in the peripheral nervous system (PNS). In the cochlea of the inner ear, arginine-like immunoreactivity was localized in satellite cells surrounding neurons of the spiral ganglion. In the dorsal root ganglia, satellite cells surrounding sensory neurons were found to be immunoreactive. In the superior cervical ganglion, L-arginine was concentrated in satellite cells around neuronal cells. In ganglia of the enteric plexus, supporting cells that covered neuronal cells were stained. These results show that free L-arginine in the PNS is concentrated in satellite and supporting cells, both of which correspond to glial cells in the CNS. Thus, those cells in ganglia of the PNS may support and/or control the neural activity by providing L-arginine to the neurons that they surround.

[Analysis of muscarinic receptors on rat pancreatic acini by using 125I-quinuclidinyl benzilate and N-[3H]-methylscopolamine]

To analyze muscarinic receptors on rat pancreatic acini, we studied the binding of 125I-quinuclidinyl benzilate (125I-QNB) and N-[3H]-methylscopolamine ([3H]-NMS) to these acini. Binding of 125I-QNB and [3H]-NMS to acini was specific and reversible. 125I-QNB bound to low affinity site, which was not recognised by [3H]-NMS. However, nonspecific binding of 125I-QNB to acini was very high (46%), so 125I-QNB may be inadequate to analyze muscarinic receptor on pancreatic acini. Muscarinic receptors are classified in two groups, M1 and M2, according to affinity of pirenzepine which binds to M1 receptor selectively. Pirenzepine was 530 times less potent than atropine in inhibiting the binding of 125I-QNB, and 250 times less potent than atropine in inhibiting the binding of [3H]-NMS. These results suggest that muscarinic receptors on pancreatic acini are mainly M2 receptors.

[Broncholithiasis: clinical experience of three operated cases]

Three patients with broncholithiasis had an operation in our hospital. Patient 1 had no history of tuberculosis. She had the pulmonary stones removed bronchoscopically twice. The stones were composed of inflammatory granulomas. Patient 2 had a history of pulmonary tuberculosis. Endoscopical removal of the pulmonary stone was not successful. After 6 days, she coughed up a large amount of blood, and the operation was performed. Patient 3 coughed up blood for 10 years. The amount of blood gradually increased and the operation was performed. All three cases had calcification of the hilar lymph nodes. Broncholithiasis appears to be related not only to pulmonary tuberculosis but also to other chronic inflammatory diseases of the lung.

Predominant localization in glial cells of free L-arginine. Immunocytochemical evidence

Nitric oxide has been recently identified as an endogenous activator of the soluble guanylate cyclase in the brain as well as in vascular endothelial cells and macrophages. In the present study, we determined the localization of free arginine in the brain because nitric oxide was formed from the terminal guanido group of L-arginine. Anti-arginine antiserum was raised in guinea pigs by repeated injection of L-arginine covalently conjugated to guinea pig serum albumin via glutaraldehyde. Specific anti-arginine antibody was purified from the antiserum by using an affinity gel coupled with L-arginine. Arginine-like immunoreactivity in the rat brain and spinal cord was found concentrated mainly in astrocytes including Bergmann glial cells in the cerebellum and processes of astrocytes around blood vessels. The present results suggest that glial cells, particularly astrocytes, are the main locus of L-arginine, a nitric oxide precursor, in the brain.