Identification of distinct N-glycosylation patterns on extracellular vesicles from small-cell and non-small-cell lung cancer cells

Asparagine-linked glycosylation (N-glycosylation) of proteins in the cancer secretome has been gaining increasing attention as a potential biomarker for cancer detection and diagnosis. Small extracellular vesicles (sEVs) constitute a large part of the cancer secretome, yet little is known about whether their N-glycosylation status reflects known cancer characteristics. Here, we investigated the N-glycosylation of sEVs released from small-cell lung carcinoma (SCLC) and non-small-cell lung carcinoma (NSCLC) cells. We found that the N-glycans of SCLC-sEVs were characterized by the presence of structural units also found in the brain N-glycome, while NSCLC-sEVs were dominated by typical lung-type N-glycans with NSCLC-associated core fucosylation. In addition, lectin-assisted N-glycoproteomics of SCLC-sEVs and NSCLC-sEVs revealed that integrin αV was commonly expressed in sEVs of both cancer cell types, while the epithelium-specific integrin α6β4 heterodimer was selectively expressed in NSCLC-sEVs. Importantly, N-glycomics of the immuno-purified integrin α6 from NSCLC-sEVs identified NSCLC-type N-glycans on this integrin subunit. Thus, we conclude that protein N-glycosylation in lung cancer sEVs may potentially reflect the histology of lung cancers.

Identification of β1-3 galactosylglucose-core free-glycans in human urine

We previously reported the precise structure of acidic free-glycans in human urine. In the present study, structural analysis of neutral free-glycans in urine was performed in fine detail. Urine samples were collected from 21 healthy volunteers and free-glycans extracted from the creatinine-adjusted urine and then fluorescently labeled with 2-aminopyridine. Neutral glycan profiling was achieved by a combination of high-performance liquid chromatography, mass spectrometry, enzymatic digestion, and periodate cleavage. A total of 79 glycans were identified. Because the ABO-blood group antigen containing urinary neutral glycans are major components, profiling patterns were similar between individuals of the same ABO-group. The neutral glycans were composed of lactose-core (Galβ1-4Glc) glycans, type-II N-acetyllactosamine-core (GlcNAcβ1-4Glc) glycans, hexose oligomers, N-glycans and to our surprise β1-3 galactosylglucose-core (Galβ1-3Glc) glycans. Although glycans with a β1-3 galactosylglucose-core were identified as major components in urine, comprising structurally simple isomers of a lactose-core, the core structure has not previously been reported. The major β1-3 galactosylglucose-core glycans were Fucα1-2Galβ1-3(Fucα1-4)Glc, GalNAcα1-3(Fucα1-2)Galβ1-3(Fucα1-4)Glc and Galα1-3(Fucα1-2)Galβ1-3(Fucα1-4)Glc, corresponding to H-, A-, and B-blood group antigens, respectively. Three lactosamine extended β1-3 galactosylglucose-core glycans were also detected as minor components. Elucidating the biosynthesis of β1-3 galactosylglucose will be crucial for understanding the in vivo function of these glycans.

Investigation of acidic free-glycans in urine and their alteration in cancer

Alterations to glycans in cancer patients have been used to identify novel tumor biomarkers. Most of these studies have focused on protein glycosylation but less attention has been paid to free-glycans. Here, we analyzed acidic free-glycans in the urine of cancer patients to identify novel tumor marker candidates. Specifically, urine samples were collected from patients with gastric cancer, pancreatic cancer and cholangiocarcinoma as well as normal controls. The free-glycans were extracted from creatinine-adjusted urine and fluorescently labeled with 2-aminopyridine. Initially, we performed profiling of urinary free-glycans by high-performance liquid chromatography and mass spectrometry with enzymatic and chemical degradation. More than 100 glycans, including novel structures, were identified. The chromatographic peaks suggested some of these glycans were present at elevated levels in cancer patients. To verify cancer-associated alterations, we compared the glycan levels between cancer patients and normal controls by selected reaction monitoring. Representative structures of glycans with elevated levels in cancer patients included the following: small glycans related to sialyllactose; sialyl Lewis X; lactose- and N-acetyllactosamine (LacNAc) type-II-core glycans with LacNAc (type-I or II)-extensions and modifications of α1,3/4-fucose and/or 6-sulfate on the Glc/GlcNAc; free-N-glycans containing sialylation or β1,6-branch of 6-sulfo Lewis X; novel NeuAcα2-3Galβ1-4(+/−Fucα1-3) Xylα1-3Glc glycans. Our results provide further insight into urinary free-glycans and suggest the potential utility of these compounds as tumor markers.

B4GALNT1 induces angiogenesis, anchorage independence growth and motility, and promotes tumorigenesis in melanoma by induction of ganglioside GM2/GD2

β-1,4-N-Acetyl-Galactosaminyltransferase 1 (B4GALNT1) encodes the key enzyme B4GALNT1 to generate gangliosides GM2/GD2. GM2/GD2 gangliosides are surface glycolipids mainly found on brain neurons as well as peripheral nerves and skin melanocytes and are reported to exacerbate the malignant potential of melanomas. In order to elucidate the mechanism, we performed functional analyses of B4GALNT1-overexpressing cells. We analyzed ganglioside pattern on four melanoma and two neuroblastoma cell lines by high performance liquid chromatography (HPLC). We overexpressed B4GALNT1 in GM2/GD2-negative human melanoma cell line (SH4) and confirmed production of GM2/GD2 by HPLC. They showed higher anchorage independence growth (AIG) in colony formation assay, and exhibited augmented motility. In vitro, cell proliferation was not affected by GM2/GD2 expression. In vivo, GM2/GD2-positive SH4 clones showed significantly higher tumorigenesis in NOD/Scid/IL2Rγ-null mice, and immunostaining of mouse CD31 revealed that GM2/GD2 induced remarkable angiogenesis. No differences were seen in melanoma stem cell and Epithelial-Mesenchymal Transition markers between GM2/GD2-positive and -negative SH4 cells. We therefore concluded that B4GALNT1, and consequently GM2/GD2, enhanced tumorigenesis via induction of angiogenesis, AIG, and cell motility. RNA-Seq suggested periostin as a potential key factor for angiogenesis and AIG. These findings may lead to development of novel therapy for refractory melanoma.

Identification of internally sialylated carbohydrate tumor marker candidates, including Sda/CAD antigens, by focused glycomic analyses utilizing the substrate specificity of neuraminidase

In our previous study, 14 sulfated carbohydrate tumor marker candidates were identified by focused glycomic analyses. Here, glycomic analyses focused on internally sialylated glycans to identify novel marker candidates. Internally sialylated glycans were enriched by digestion of pyridylaminated glycans prepared from sera with α-neuraminidase from Salmonella typhimurium, which did not cleave sialic acids linked to internal residues, followed by anion-exchange chromatography. Next, internally sialylated O-glycan profiles were constructed using two types of high performance liquid chromatography, which were compared between 20 healthy controls and 11 patients with gastric cancer and 9 patients with pancreatic cancer. In all, 17 marker candidates were identified. The structures of glycan candidates were precisely analyzed using enzymatic digestion, glycan synthesis, 2D mapping and mass spectrometry. Among 17 candidates, one was STn, and the other 16 comprised 10 core1, 1 core2 and 5 core3 glycans. The various structures included a α2,6-sialylated reducing terminal GalNAc and α2,6-sialylated type1 N-acetyl-lactosamine. Eight candidates possessed the Sda/CAD antigen. The levels of these candidate glycans in sera from all 40 subjects were quantified using a selected reaction monitoring assay and found to be elevated in at least one or more patients. Although the serum levels of each candidate glycan varied between patients, those candidates having the same backbone or determinant, such as core3 backbone and core1 structures with extended type1 N-acetyl-lactosamine, displayed similar patterns of elevation. These results suggest that analysis of multiple markers may be an effective means of diagnosing various cancers.

Correlation of serum sialyl Tn antigen values determined by immunoassay and SRM based method

We previously identified four glycan tumor marker candidates using a HPLC-based method. One candidate was sialyl Tn (STN), NeuAcα2-6-GalNAc. In this study, glycans were prepared from sera by hydrazine treatment followed by fluorescent labeling with aminopyridine. Pyridylaminated-STN levels of 147 gastric cancer, 85 pancreatic cancer and 10 cholangiocarcinoma patients together with 102 normal controls were accurately quantified using HPLC separation followed by selected reaction monitoring (SRM) assay, which used a stable isotope, tetradeuterium-labeled pyridylamino glycan as an internal standard. Additionally, STN values were also quantified using conventional competitive inhibition radioimmunoassay (RIA). The two STN levels determined by RIA and SRM gave a similar distribution pattern in sera. STN levels were increased in sera from cancer patients compared to those from normal controls. Moreover, the STN levels in sera of cancer patients determined by the two different assay procedures showed a good correlation (i.e., correlation coefficient >0.9). Our results suggest it may be better to determine STN levels using SRM instead of RIA.

Structures and developmental alterations of N-glycans of zebrafish embryos

Zebrafish is a model organism suitable for studying vertebrate development. We analyzed the N-glycan structures of zebrafish embryos and their alterations during zebrafish embryogenesis to obtain basic data for studying the roles of N-glycosylation. Multiple modes of high-performance liquid chromatography and multistage mass spectrometry were used for structural analysis of N-glycans. The N-glycans from deyolked embryos at 36 hours postfertilization, a mid-pharyngula stage, contained relatively higher amounts of complex- and hybrid-type glycans with LacNAc (Galβ1-4GlcNAc) and/or sialyl LacNAc without additional β1,4-Gal, which are commonly found in mammalian tissues, as well as abundant oligomannose-type glycans. Some of the complex- and hybrid-type glycans possessed various extended LacNAc structures, such as Galβ1-4LacNAc, LacNAc-repeat or unique (+/- dHex)-GalNAcα1-GlcNAcβ1-LacNAc. In contrast, the yolk of the embryo contains predominant oligomannose-type glycans and complex-type glycans with Galβ1-4(Siaα2-3)Galβ1-4(Fucα1-3)GlcNAc antennae. N-Glycan profiles obtained from deyolked embryos at different stages showed stage-dependent variation of complex- and hybrid-type glycans. At gastrula and early segmentation stages, complex- and hybrid-type glycans were minor components, and their antenna structures were mainly sialyl LacdiNAc (Siaα2-6GalNAcβ1-4GlcNAc). From the mid-segmentation to pharyngula stages, those with LacNAc and/or α2,6-sialyl LacNAc antenna structures increased remarkably, and those with α2,3-sialyl LacNAc antenna, core α1,6-Fuc and bisecting GlcNAc modifications increased gradually. These results suggest the presence of mechanisms for regulating the antenna structures of complex/hybrid N-glycan biosynthesis in the phylotypic stage of vertebrate development.

Deep venous thrombosis among disaster shelter inhabitants following the March 2011 earthquake and tsunami in Japan: a descriptive study

Objectives

A retrospective analysis of data collected during subject screening following Japan's March 2011 earthquake and tsunami was performed. We aimed to determine the incidence of deep venous thrombosis (DVT) among screened subjects and to identify risk factors associated with the development of DVT as independent variables.

Methods

Calf ultrasonography was undertaken in 269 subjects living in 21 shelters in Miyagi prefecture during the one-month period immediately following the March 2011 disaster. Information regarding the health and risk factors of subjects was collected by questionnaire and assessment of physical signs.

Results

Of the 269 evacuees screened, 65 (24%) met the criteria for calf DVT. We found lower limb trauma, reduced frequency of urination and sleeping in a vehicle to be independent positive predictors of DVT.

Conclusions

Evacuees had an increased risk of developing DVT, associated with tsunami-related lower limb injury, immobility and dehydration.

Mapping of equine potassium chloride co-transporter (SLC12A4) and amino acid transporter (SLC7A10) and preliminary studies on associations between SNPs from SLC12A4, SLC7A10 and SLC7A9 and osmotic fragility of erythrocytes

Consensus DNA sequences from human, mouse and/or rat were used to design oligonucleotide primers for equine homologues of exons 16, 17 and 20-23 of potassium chloride co-transporter (SLC12A4) and exons 10, 11 and 3, 4, respectively, for two amino acid transporters (SLC7A10 and SLC7A9). DNA sequences of the PCR products showed high sequence identity to these regions. Equine BAC clones were obtained for SLC12A4 and SLC7A10 and mapped to equine chromosomes ECA3p13 and ECA10p15, respectively, by fluorescence in situ hybridization (FISH). Several single nucleotide polymorphisms (SNP) were found. Substitutions of A/G were found within exon 17 of SLC12A4, within intron 11 of SLC7A10 and within intron 3 of SLC7A9. The SNP associated with SLC7A10 and SLC7A9 were sufficiently polymorphic to investigate associations with erythrocyte fragility among a group of 20 thoroughbred horses. A non-parametric rank-sum test showed a weak association between erythrocyte fragility and the SNP associated with SLC7A10 (P < 0.05).

Neutrophil proteinase 3-mediated induction of bioactive IL-18 secretion by human oral epithelial cells

IL-18, a potent IFN-gamma-inducing cytokine, is expressed by various nonimmune cells as well as macrophages, suggesting that it has important physiological and immunological roles. The present study focused on the mechanism of active IL-18 induction from human oral epithelial cells. The epithelial cells and the cell lines constitutively express IL-18 mRNA and the 24-kDa precursor form of IL-18. Bioactive IL-18 exhibiting IFN-gamma-inducing activity was detected in the supernatant of the cells on costimulation with neutrophil proteinase 3 (PR3) and LPS for 24 h after IFN-gamma-priming for 3 days. An active 18-kDa form of IL-18 was detected in lysate and supernatant of the cells only after the above treatment and the induction was inhibited by cycloheximide and by serine proteinase inhibitors. After the treatment, lactate dehydrogenase activity was not detected in the cell culture supernatant, and PR3 was detected only in the membrane and not in cytoplasm fractions of the cells. Caspase-1 was not detected in the cells even after the treatment and the IL-18 induction was not inhibited by a caspase-1 inhibitor. These results suggest that the PR3-mediated induction of bioactive IL-18 secretion from oral epithelial cells in combination with LPS after IFN-gamma-priming occurred via a caspase-1-independent pathway, and provide new insight into the possible involvement of a neutrophil proteinase in the induction of bioactive IL-18 in oral inflammation such as periodontitis.

[An unconscious patients with ascending aortic aneurysm accompanied by aortic regurgitation successfully treated by emergency operation after cardiopulmonary resuscitation]

A-37-year-old woman in shock condition was transferred to our hospital after cardiopulmonary resuscitation for ventricular fibrillation. She was unconscious and suspected of suffering ischemic brain damage, with pathologic reflexes and weak brain stem reflexes. Brain CT scan showed cerebral edema without hemorrhage or infarction and an electroencephalograph revealed slow alpha-theta waves. Chest CT scan and echocardiogram showed ascending aortic aneurysm with sever aortic regurgitation. An emergent operation was performed for progression of heart failure. There were no distortion or dilatation of the sinus of Valsalva and annuloaortic ectasia and aortic valve leaflets were almost normal. We considered that the aortic valve dysfunction was cause by dilatation of the sinotubular junction. Ascending aortic and aortic valve replacement were carried out to shorten cardiopulmonary bypass time and to prevent the progression of brain damage. Mild hypothermia was employed as a neuroprotective procedure for three days after surgery. The patient's neurological symptoms, which were right hemiparesis, facial apraxia and motor aphasia, improved and she was discharged from the hospital on foot without any neurological complications on the 47th postoperative day and returned to work after two months.

Direct Cardiac Potential Trigger for Chronic Control of a Ventricular Assist Device

As a new trigger method for chronic drive control of a ventricular assist device (VAD), a direct cardiac potential trigger was assessed under various conditions in a chronic experimental model. A pneumatic pulsatile VAD was implanted as circulatory support between the left ventricular apex and the ascending aorta in 12 adult pigs. Hemodynamic parameters and pump output were continuously monitored. Two tips of a bipolar electrode were set on the RV anterior wall and the LV posterior wall for recording direct cardiac potential. Counterpulsation drive of the VAD was applied by using the R wave in a standard electrocardiogram (ECG) or the direct cardiac potential as an ECG trigger. As special conditions, various artifacts on ECG, electromusculogram, arrhythmia, irregular ventilation, and passive vibration (simulation of exercise) were set for assessing the ECG trigger modes. Artifacts of irregular ventilation and passive vibration made the drive control poor using a standard ECG trigger. In contrast, the direct cardiac potential trigger maintained the counterpulsation control of the VAD well in all conditions of this study, and was a safe and reliable support for the native heart. It also supported animals for up to 48 hours after operation. The above results suggested that the direct cardiac potential trigger might be useful for monitoring native heart beats and adjusting the support cycle to the native heart cycle as a chronic control method for various VADs.

[Perioperative management of a patient with general lymph-congestion following total spondylectomy with posterior and anterior fusion for first thoracic vertebral hemangioma]

A 50-year-old healthy woman was scheduled for surgery of the first thoracic vertebral (T 1) hemangioma accompanying rapidly aggravated neurological deficit in three months. Anesthesia was induced with intravenous fentanyl and propofol and maintained with isoflurane-oxygen-air inhalation, followed by propofol infusion combined with sevoflurane inhalation. Following posterior decompression of T 1 with fusion of C 6-T 3, consecutive total spondylectomy of T 1 with anterior fusion of C 7-T 2 was carried out. At the end of surgery, marked edema was noticed on her face, neck and bilateral upper extremities, possibly due to long manipulation around the left jugular angle. Next morning the edema spread to her whole body and the elevation of both diaphragms and the mediastinal expansion were recognized. Mechanical ventilation in the mode of IMV was performed until subsiding of edema on the fifth postoperative day. During this period, hypoxemia was frequently observed in spite of appropriate respiratory support. On the third postoperative day, bronchoscopic bronchial toilet was performed which brought the improvement of blood oxygenation. The occasional administration of furosemide was not effective to reduce general edema, but served for the acceleration of lymphatic drainage after the release of the thoracic duct obstruction and the patient was extubated uneventfully on the sixth postoperative day.

Fragility of red cells during exercise is affected by blood pH and temperature

We examined the relationship in horses between osmotic fragility of erythrocytes (OFE) measured as the red cell haemolysis rates (HLR) in 0.56% NaCl and certain physiological characters. Animals were exercised on a treadmill: warmed up at 30% VO2max for 5 min or at 105% VO2max for 1 min, given an exercise test at 80 or 105% VO2max until fatigued, and then cooled down. The pH and temperature of the blood had a significant correlation for the HLR: r = 0.93 and 0.92 (P < 0.01) on arterial and mixed venous blood, respectively. In multiple regression analysis, heart rate and packed cell volume showed lower coefficients for the HLR. The present study suggested that, in exercising horses, 1) the increase of blood flow and release of erythrocytes from the spleen into the circulation have little effect on changes of OFE; 2) the decrease of blood pH promotes OFE; 3) the increase of the pH causes osmotic resistance in the cells and 4) an increase of blood temperature during exercise is associated with the decrease in the OFE.

Anesthetic management for pheochromocytoma resection using spinal cord stimulation and intravenous nicardipine--a case report

We have used spinal cord stimulation (SCS), diazepam and nitrous oxide for maintenance of general anesthesia. Blood pressure was maintained by bolus administration of nicardipine for the removal of pheochromocytoma. Both SCS and nicardipine reduced systemic vascular resistance and SCS increased cardiac output. However, neither SCS nor nicardipine could inhibit the release of norepinephrine. SCS proved to be useful as one of anesthetic technique during the removal of pheochromocytoma, and also in the management of postoperative pain and the prevention of complications.

Gene organization of the quail major histocompatibility complex (MhcCoja) class I gene region

Class I genomic clones of the quail (Coturnix japonica) major histocompatibility complex (MhcCoja) were isolated and characterized. Two clusters spanning the 90.8 kilobase (kb) and 78.2 kb class I gene regions were defined by overlapping cosmid clones and found to contain at least twelve class I loci. However, unlike in the chicken Mhc, no evidence for the existence of any Coja class II gene was obtained in these two clusters. Based on comparative analysis of the genomic sequences with those of the cDNA clones, Coja-A, Coja-B, Coja-C, and Coja-D (Shiina et al. 1999), these twelve loci were assigned to represent one Coja-A gene, two Coja-B genes (Coja-B1 and -B2), four Coja-C genes (Coja-C1-C4), four Coja-D genes (Coja-D1-D4), and one new Coja-E gene. A class I gene-rich segment of 24.6 kb in which five of these genes (Coja-B1, -B2, -D1, -D2 and -E) are densely packed were sequenced by the shotgun strategy. All of these five class I genes are very compact in size [2089 base pairs (bp)-2732 bp] and contain no apparent genetic defect for functional expression. A transporter associated with the antigen processing (TAP) gene was identified in this class I gene-rich segment. These results suggest that the quail class I region is physically separated from the class II region and characterized by a large number of the expressible class I loci (at least seven) in contrast to the chicken Mhc, where the class I and class II regions are not clearly differentiated and only at most three expressed class I loci so far have been recognized.

"Tail sign" associated with microembolic signals

BACKGROUND AND PURPOSE

Transcranial Doppler ultrasound (TCD) can detect circulating microembolic signals (MES). We focused our attention on tail signs (TS), a signal associated with MES that appeared as a small reversal signal after MES on the high time resolution spectral display. We examined MES and artifacts in an animal study to determine whether TS were specific changes associated with MES and investigated the characteristics of TS in both animal and clinical studies.

METHODS

In an animal study, adult pigs with venoarterial extracorporeal membrane oxygenation and minimal anticoagulation therapy were used as a model for cerebral embolism. After performing TCD monitoring with a multigated approach, we did an offline analysis to investigate several parameters concerning MES and TS. We also examined TS in patients in a clinical study.

RESULTS

From a total of 362 MES investigated in the animal study, 72.9% were followed by TS. We could not find any TS associated with artifacts. The time delay between TS and MES was negatively correlated with the velocity of MES. MES almost always appeared first in the proximal channel, whereas TS conversely appeared first in the distal channel. In the clinical study, we were also able to observe TS associated with MES.

CONCLUSIONS

TS may represent emboli passing down a branch vessel or twisted downstream vessel. TS are specific for MES and can be used as another criterion for MES identification.

The effect of fibrin glue on inhibition of pericardial adhesions

The effect of fibrin glue on inhibition of pericardial adhesions was tested using 26 beagle dogs. Dacron patches were sutured to the heart and tincture of iodine was applied to promote adhesions. Fibrin glue (3 ml) was sprayed over the patches in 15 dogs (test group), and was not separated in the remaining 11 dogs (control group). All animals in the test group had minimal adhesions between the pericardium and the epicardium or patched region, and an accumulation of gelatinous material was found in the subpericardial space. Marked fibrosis and a poor demarcation of the subpericardial space were found in the control group. The adhesion score and the visibility of coronary anatomy in the test group were significantly better than in the control group. The tension strength in the test group was significantly less than in the control group. We concluded, therefore, that fibrin glue may also be useful as an adhesion inhibitor.

Left atrial ball thrombi without mitral valve disease treated by surgical removal

We describe two patients with free-floating left atrial ball thrombi with no evidence of cardiac disease except atrial fibrillation. One patient had experienced an embolic stroke, and the second patient had a history of stroke and peripheral thromboembolism. In each patient, the thrombi, which were not visible on transthoracic echocardiography, were detected by transesophageal echocardiography. Each patient underwent successful surgical removal using cardiopulmonary bypass.

[Traumatic aortic regurgitation: report of two surgical cases]

Two successful surgical cases with aortic regurgitation due to blunt trauma are reported. Case 1: A 48-year-old female was transferred to our hospital after a traffic accident. She was intubated and mechanically ventilated. Twelve days later, echocardiography demonstrated massive aortic regurgitation. The next day, aortic valve replacement was performed using a 21 mm SJM mechanical valve. The central part of the non-coronary cusp was torn and perforated 15 mm long. She is in good condition three years after surgery. Case 2: A 57-year-old male was transferred to the nearest hospital because he was involved in a snowslide accident. A month after the injury, catheterization showed massive aortic regurgitation and pulmonary hypertension. An aortotomy revealed that the intima around the right coronary ostium was completely torn. A perforation with a diameter of 3 mm was also observed on the right coronary cusp. After coronary cusps were excised, interrupted mattress sutures buttressed with pledgets were passed through the aortic wall at the distal level of the intimal laceration and then to the aortic annulus. A 25 mm SJM prosthetic valve was seated at the aortic ring. As the right coronary ostium was included in the plicated aortic wall, aortocoronary bypass was constructed using the great saphenous vein. He is doing well 14 months after surgery. Aortic regurgitation due to blunt trauma is rare and difficult to diagnose. Sometimes cardiac failure progresses rapidly. Therefore, urgent surgery is recommended as soon as the diagnosis is confirmed.

[Cerebral embolism due to left atrial ball thrombus without mitral stenosis--usefulness of the transesophageal echocardiography for the diagnosis]

We reported two cases of cerebral embolism associated with atrial fibrillation. Left atrial ball thrombus without mitral stenosis was diagnosed by the transesophageal echocardiography, followed by successful removal. Left atrial ball thrombus has a risk for lethal complications, and a high incidence of systemic embolism even during anticoagulation therapy. An immediate surgical treatment is needed. The transthoracic echocardiography is not useful in diagnosis for left atrial ball thrombus. It is important to examine left atrial ball thrombus by the transesophageal echocardiography in patients with cerebral embolism associated with atrial fibrillation.

[A survival case of intraoperative pulmonary embolism diagnosed early by transesophageal echocardiography]

An otherwise healthy 36-year-old housewife was diagnosed with advanced cancer of the stomach 5 months after her third parturition. Surgery was performed with the patient under total intravenous anesthesia combined with continuous epidural anesthesia. The course of anesthesia and the operative course were uneventful until the abdominal skin was sutured, when unexplained severe circulatory collapse developed. A widely dissociated PETCO2- PaCO2 suggested pulmonary embolism, and the findings of transesophageal echocardiography corroborated the diagnosis. Infusion of 480,000 units of urokinase in 30 minutes was immediately started via a Swan-Ganz catheter, and intravenous heparin 10,000 units in 24 hours, was administrated continuously. The pulmonary circulation was restored 30 minutes after the start of therapy, resulting in rapid recovery of the patient's systemic circulatory and acid-base status. The patient was safely extubated 19 hours postoperatively.

[Epidural anesthesia for herniorrhaphy in a patient with severe dilated cardiomyopathy (DCM) under pimobendan control]

A 60-year-old man with severe DCM was scheduled for a herniorrhaphy under epidural anesthesia using fentanyl. Three months prior to operation, the patient suffered heart failure associated with life-threatening ventricular arrhythmia. The former was successfully treated with pimobendan as the main constituent of medication, but the latter was not responsive to various antiarrhythmic drugs with the exception of aprindine. On the day of operation and for two days postoperatively, pimobendan was administered daily. A sudden drop in systemic blood pressure and central venous pressure (CVP) during anesthesia, as well as the tendency to hypotensive status in the postoperative period were well regulated with continuous infusion of dopamine and dobutamine via CVP catheter probably due to the effect of up-regulation of pimobendan, together with adjustment of the volume of intravenous fluids. No dangerous ventricular arrhythmia were observed. Thereafter the patient made uneventful progress and was discharged on the 8th postoperative day.

Effects of partial blood replacement with pyridoxalated hemoglobin polyoxyethylene conjugate solution on transient cerebral ischemia in gerbil

Blood components were reported to be aggravating factors of ischemic cerebral injury. We previously reported that a partial blood replacement with Fluosol DA reduced ischemic neuronal injury. The purpose of this study is to elucidate whether pyridoxalated hemoglobin polyoxyethylene conjugate solution (PHP) exerts neuro-projective effects against cerebral ischemia.

METHODS

38 adult male gerbils were divided into 4 groups, such as normal group without ischemia or treatment, PHP group undergoing an exchanging blood transfusion with 5.0 ml PHP, ischemia group undergoing 5-min forebrain ischemia, and PHP-ischemia group with 5.0 ml PHP partial blood replacement prior to 5-min forebrain ischemia. Cerebral injury was assessed 7 days after treatment. In another group, effects of PHP on blood nitric oxide (NO) and cerebral blood flow (CBF) were studied.

RESULTS

CA1 cell density was 140-2/mm in normal group and 142-5/mm in PHP group. The cell density was markedly reduced to 38-13 in ischemia group. The cell density was further reduced 27-10/mm in PHP-ischemia group. PHP was found to have a potent NO scavenger action and reduce CBF.

CONCLUSION

Partial blood replacement with PHP prior to ischemia may cause cerebral vasoconstriction due to NO scavenger action and may worsen ischemic injury.

[Anesthetic problems in a 480 g infant for ventriculo-peritoneal shunt surgery]

A 480 g, 38-day-old female infant underwent ventriculo-peritoneal shunt surgery for hydrocephalus after intra-ventricular hemorrhage. The patient was born at a gestational age of 25 weeks and 5 days, weighing 600 g, as one of twins by a cesarean section. Although respiratory distress syndrome developed, it was relieved with surfactant. The esophagus was easily perforated by a gastric tube. At the age of 7 days, PDA was closed conservatively with indomethacin. Anesthesia was induced and maintained with fentanyl (induction dose 4 micrograms.kg-1, total dose 6 micrograms.kg-1) and vecuronium. Ventilation was controlled with oxygen and air (FIO2 0.21-0.25). The main problems encountered by anesthetists in the perioperative period were; fluid management (hyperkalemia, hyponatremia, infusion volume), bradycardia due to increased intracranial pressure, body temperature control (hypothermia), and transport to the operating room. In anesthesia for extremely low birth weight (extremely premature) infants, utmost care and proficient procedure are required because of their immaturity, fragility and smallness.

[Unexpected intraoperative respiratory distress; an infant who developed tracheomalacia and fatal aortoesophageal fistula due to unrecognized vascular ring]

Vascular rings cause respiratory distress and dysphasia by tracheoesophageal compression. We present a case of tracheomalasia and fatal aortoesophageal fistula due to unrecognized vascular ring. A 3-month-old (7.3 kg) boy underwent V-P shunt operation under sevoflurane anesthesia. The trachea was intubated easily using vecuronium with a relatively large-size tube with a diameter of 4.5 mm, because of leakage. Gastric intubation was difficult. During scrubbing of the head, an asthma-like respiratory distress suddenly occurred. The condition responded poorly to ventilatory support and pharmacological interventions. Although intraoperative fiberscopy through the tracheal tube and chest X-ray showed no tracheobroncheal abnormality, postoperative fiberscopy revealed a tracheomalacia. Adequate ventilation was possible only when the tip of the tracheal tube was located between the stenotic part and the tracheal carina. On the 9th postoperative day, during respiratory management with a tracheal tube, fatal esophageal hemorrhage broke out. Postmortern examination revealed a double aortic arch with tracheal stenosis and aortoesophageal fistula. The nasogastric tube may have led to fistula formation by compression of the esophageal wall against an anomalous vessel. When anesthetists encounter an infantile respiratory distress, even in perioperative period, vascular rings should be taken into consideration.

[Tetralogy of Fallot with a restrictive ventricular septal defect caused by a membranous flap]

A 5-year-old boy who had typical tetralogy of Fallot (TOF) with mild cyanosis was referred to us. Preoperative echocardiogram revealed that in addition to the TOF morphology, an abnormal piece of tissue attached to the right side of the ventricular septum was floating and obstructing flow through the ventricular septal defect (VSD) in systole. Preoperative cardiac catheterization showed suprasystemic right ventricular pressure with a gradient of 60 mmHg between the right ventricle and the aorta, and a right ventriculogram demonstrated a narrow radiolucent structure beneath the aortic valve in the right ventricle. During surgery a fibrous membranous tissue, with no relation to the tricuspid valve, was found to extend from the edge of the VSD to the aortic valve and to partially occlude the defect. This tissue was used as a suture anchorage for patch closure of the defect. Preoperative echocardiography is useful to detect such flaps and early surgical correction should be done to prevent right ventricular failure resulting from right ventricular pressure overload.

[Successful primary correction for tetralogy of Fallot associated with total anomalous pulmonary venous drainage (type Ia)]

The surgical correction was performed successfully in a 3-year-old girl with tetralogy of Fallot associated with total anomalous pulmonary venous drainage (type Ia). The preoperative cardiac catheterization and angiography showed high systolic pulmonary artery pressure (58 mmHg) and small left ventricular volume (54% of normal). The early postoperative course was stormy because of the unstable circulatory state. During the early postoperative period, we estimated the volume of left ventricle by 2 D echocardiography. A significant increase of the volume was observed on the 8th postoperative day, when her circulatory state became stable. The cardiac catheterization before discharge revealed Pp/Ps of 0.38 and normal LV volume. We conclude that primary repair should be done for this combined cardiac anomaly, even if small left ventricle and pulmonary hypertension is present.

[The protective effect and problem of retrograde cerebral perfusion]

In order to study the protective effect and problem of retrograde perfusion (RCP), cerebral hemodynamics and cerebral metabolism were evaluated in fourteen pigs weighing 25-30 kg. Intracranial pressure, carotid arterial flow and pressure, and internal jugular venous pressure as cerebral hemodynamics; pyruvate, lactate, and oxygen consumption as cerebral metabolism; and brain temperature were measured. The animal was cooled to electrical cerebral silence on electroencephalogram under cardiopulmonary bypass. Then, animals were divided into three groups: group I (n = 4); circulatory arrest; group II (n = 3); RCP through superior vena cava (SVC); group III (n = 7); RCP through bilateral internal jugular vein (IJV). Retrograde perfusion flow was regulated to maintain the SVC pressure or IJV pressure of 30 mmHg, for 90 minutes. The variations in brain temperature were least in group III. As perfusion flow increased, intracranial pressure, and inferior vena cava (IVC) pressure increased. But, cerebral perfusion pressure, which was calculated from the difference of intracranial arteriovenous pressure, did not increase and, SVC pressure and returned blood flow through the aorta did not increase in group III. In group II, there was no significant relation between pump flow, SVC pressure, and intracranial pressure, but SVC pressure had a positive correlation with the pressure gradient of SVC-IJV. The uptake of cerebral lactate, cerebral pyruvate, and lactate-pyruvate ratio, and cerebral oxygen consumption were superior in group III than other groups. In conclusion, RCP through IJV was advantageous to maintain hypothermia and aerobic metabolism of the brain during systemic hypothermic circulatory arrest.(ABSTRACT TRUNCATED AT 250 WORDS)

[The study on cerebral hemodynamics during selective cerebral perfusion]

This study was undertaken to clarify characterization on cerebral hemodynamics during deep hypothermic selective perfusion (SCP) in 18 pigs. Besides, the changes on cerebral hemodynamics were investigated with obstruction to venous drainage due to the clamp of superior vena cava (SVC) cannula. For SCP, blood was infused into aortic arch with the clamp of descending aorta, during 90 minutes at 20 degrees C. We measured regional cerebral blood flow (CBF), intracranial pressure (ICP), and carotid arterial flow (CAF), and carotid arterial pressure. The carotid arterial pressure as perfusion pressure was not significantly correlated with CAF, CBF and ICP. Although CAF increased as pump flow rate increased, the relationship between pump flow and CBF was not significant. Moreover, SVC pressure showed a tendency to increase, as CAF increased. Both ICP and internal jugular vein pressure (IJVP) were significantly (p < 0.01) increase, and CAF was significantly (p < 0.05) decrease with the clamp of SVC cannula. On the other hand, both ICP and IJVP were significantly decrease, and both CAF and CBF were increase, without unclamp of SVC cannula. The results suggest that cerebral autoregulation is intact during deep hypothermic SCP, and hyperperfusion cause the increase of shunt flow in extracranial area, and besides, the increase of ICP with obstruction to venous drainage cause decrease in cerebral blood flow.

[Flow characteristics and responses to vasoactive drugs in canine gastroepiploic artery]

We studied flow characteristics and response to norepinephrine, Chlorpromazine and gastrin in 22 canine gastroepiploic artery (GEA) recirculation model. The GEA flow was obtained by a drip for a minute, opening the end of pedicle GEA. Furthermore, aortic flow and celiac arterial flow were measured by magnetic flow probe. The administration of chlorpromazine, vagostigumine, and gastrin induced a increase in both celiac arterial flow and pedicle GEA graft flow. Especially, the administration of gastrin induced significant increase in GEA flow and celiac arterial flow. Furthermore, adding norepinephrine step-wisely, the GEA flow increased remarkably, in spite of decrease of celiac arterial flow. This response was caused from difference in vascular resistance among celiac arterial branches. Therefore, the pedicle GEA graft has homogenous response as same as intact GEA that perfuses stomach, because its flow was affected by adrenergic and parasympathetic agent, alpha-blocker and gastric hormone.

[Anesthetic management of palliative surgery for hypoplastic left heart syndrome--a case report]

The first patient with hypoplastic left heart syndrome who was treated successfully by palliative surgery at our hospital is reported. Soon after birth, the female infant showed tachypnea and cyanosis, and was transferred to our institution under a presumptive diagnosis of HLHS. Although cardiologists confirmed the diagnosis by two-dimensional echocardiography, the surgery was postponed for one month because it was possible to keep the ductus arteriosus open without PGE1, and the patient showed no deterioration. Fortunately, an abnormal vessel connecting the left atrium with the superior vena cava relieved severe pulmonary venous congestion by diverting the blood flow. During the pre-CPB period, frequent adjustment of the oxygen concentration and ventilator setting was required in order to keep the blood gas values optimal compared with the values before surgery. After CPB, adequate blood pressure using catecholamines and hyperventilation with 100% oxygen was necessary to increase the pulmonary blood flow and to decrease the pulmonary vascular resistance. It is concluded that preservation of the balance between PVR and SVR during the perioperative period, and adequate systemic arterial pressure after CPB are crucial. Furthermore, constant and intense observation is mandatory to facilitate immediate treatment even after surgery in case of systemic hypoperfusion due to excessive pulmonary blood flow.

Scopolamine patch reduces postoperative emesis in paediatric patients following strabismus surgery

Scopolamine patch was evaluated for the prevention of postoperative emesis in 50 children undergoing strabismus surgery. All subjects were premedicated, with none receiving narcotic premedicants. Anaesthesia included controlled ventilation with the use of muscle relaxants, atropine, and halothane. Before operation, the subjects were randomly assigned to one of two groups: a treatment group received a scopolamine patch at a dose of either 0.75 mg or 0.375 mg, and a control group received no patch. Both the incidence and frequency of vomiting in the scopolamine-treated group were significantly (P less than 0.05) lower than in the control group.

Accidental extubations during respiratory management in a children’s hospital

An investigation was conducted on the frequency of accidental extubations at Shizuoka Children's Hospital during the past 12 years. The study was performed on 150 randomly selected patients who received respiratory support for more than 24 hr. Fifteen accidental extubations occurred in 9 patients. Most of them (87%) occurred in the neonatal intensive care unit (NICU), and the rate was 1 per 54 days of intubation. The time at which these accidents happened varied, although they were more common during the day-time. The reasons of accidental extubation could not be specified in two-thirds of the cases. It became clear that more immature babies were more likely to suffer accidental extubation, perhaps reflecting the fact that most of the immature babies in the NICU were intubated orally, and that a larger proportion of them required a longer period of respiratory support. Therefore, early weaning from respiratory support is recommended if it is possible. In conclusion, increased surveillance and more secure methods of taping of endotracheal tubes are crucial for preventing life-threatening accidental extubations during respiratory support.

Diagnosis of submucosal tumor by injecting a water soluble contrast medium: development pattern and growing of tumors

With the application of our endoscopical method of contrasted X-ray imaging, gastric submucosal tumors were studied with chief regards to their modes of growing up and patterns of development. It has become known that, of extra-gastric developing tumors, larger ones tend to show Pattern IVa and smaller ones Pattern IVb. Generally, the tumors showed a tendency of becoming larger in older patients. Periodical checking disclosed about 15% of the tumors growing larger with the lapse of time. It has been surmised that as tumors grow up, their development possibly turns from intra-gastric to intramural and mingled in pattern. Their modes of growing could be classified as follows: Abruptly growing large at a certain time and then remaining without notable changes, step-by-step enlarging, and gradually growing up straight forwardly with years.

Cytological diagnosis of leiomyogenic tumors of the stomach

The cytological findings in 7 cases of leiomyoma and 4 cases of leiomyosarcoma can be summarized as follows: For differential diagnosis of these lesions, in comparison with leiomyoma cells, leiomyosarcoma cells were found to have 1) increased minor axis diameters of the nuclei and nuclear anisokaryosis, 2) dark nuclear staining, 3) enlarged and darkly stained chromocenters, 4) dark staining and thickening of the nuclear rim, 5) enlargement of nuclear clear areas, 6) increased numbers of oval nuclei and greater pleomorphism, 7) an increase in size and number of the nucleoli, 8) a strong tendency for cell atypism, such as anisocytosis and pleomorphism. In the light of these findings, it is believed that differential diagnosis is indeed possible.