Implantation of a Dual-chamber Pacemaker in a Patient with Dextrocardia, Situs Inversus, and Sick Sinus Syndrome

Situs inversus with dextrocardia is a rare congenital anomaly that presents a unique challenge for the consultant electrophysiologist. Implantation of cardiac device in these patients may be challenging owing to their individual cardiac and vascular anatomy. Consequently, adverse procedural outcomes are more common in this group and an informed pre- and intraoperative approach is critical. In this article, we present the relevant patient findings and implications for the electrophysiologist, including operative approaches. We then examine them in the context of an actual case, having implanted an intracardiac permanent pacemaker with a right-sided approach via the conventional method in a patient with dextrocardia situs inversus who had undergone multiple surgeries for structural heart disease.

Aging and sleep deprivation induce the unfolded protein response in the pancreas: implications for metabolism

Sleep disruption has detrimental effects on glucose metabolism through pathways that remain poorly defined. Although numerous studies have examined the consequences of sleep deprivation (SD) in the brain, few have directly tested its effects on peripheral organs. We examined several tissues in mice for induction of the unfolded protein response (UPR) following acute SD. In young animals, we found a robust induction of BiP in the pancreas, indicating an active UPR. At baseline, pancreata from aged animals exhibited a marked increase in a pro-apoptotic transcription factor, CHOP, that was amplified by SD, whereas BiP induction was not observed, suggesting a maladaptive response to cellular stress with age. Acute SD increased plasma glucose levels in both young and old animals. However, this change was not overtly related to stress in the pancreatic beta cells, as plasma insulin levels were not lower following acute SD. Accordingly, animals subjected to acute SD remained tolerant to a glucose challenge. In a chronic SD experiment, young mice were found to be sensitized to insulin and have improved glycemic control, whereas aged animals became hyperglycemic and failed to maintain appropriate plasma insulin concentrations. Our results show that both age and SD cooperate to induce the UPR in pancreatic tissue. While changes in insulin secretion are unlikely to play a major role in the acute effects of SD, CHOP induction in pancreatic tissues suggests that chronic SD may contribute to the loss or dysfunction of endocrine cells and that these effects may be exacerbated by normal aging.

Transarterial intravenous coil embolization of dural arteriovenous fistula involving the superior sagittal sinus

BACKGROUND

We report a rare case of traumatic dural arteriovenous fistula involving the superior sagittal sinus successfully treated by transarterial intravenous coil embolization.

CASE PRESENTATION

A 38-year-old woman presented with tension headache. She had a past history of severe head injury at the age of three. Computed tomography scanning showed a heterogenous low-density area in the right frontal lobe, and magnetic resonance imaging demonstrated abnormal vascular structures in the same area. Angiography revealed a dural arteriovenous fistula involving the lateral wall of the fully patent superior sagittal sinus. The fistula was fed by scalp, meningeal, and cortical arteries, and drained into a cortical vein leading to the superior sagittal sinus. Femoral transarterial intravenous embolization with microcoils completely occluded the dural arteriovenous fistula.

CONCLUSION

Severe head injury may lead to asymptomatic dural arteriovenous fistulas after a long time. Transarterial intravenous coil embolization can be effective in the treatment of dural arteriovenous fistulas involving the superior sagittal sinus.

[When do strokes occur?--analysis of diurnal variation and activity during the onset]

The diurnal variation and activity during the onset of stroke were examined in more than 700 consecutive patients. 304 cases with hypertensive intracerebral hemorrhage (HIH), 214 cases with subarachnoid hemorrhage (SAH) and 201 cases with obstructive cerebrovascular disease (OCVD) were investigated about the time of onset. Concerning the activity during the onset, 296 cases with HIH, 215 cases with SAH and 198 cases with OCVD were examined. HIH occurred frequently between 1500-1800 hours, 0600-0900 hours and 1800-2100 hours. SAH occurred frequently between 0900-1200 hours, 1500-1800 hours and 1800-2100 hours. Both HIH and SAH were least likely to occur between 0000-0300 hours. OCVD exhibited a small peak incidence between 0900-1200 hours, but there were no differences between the groups for the other time periods. Both HIH and SAH were likely to occur frequently in the lavatory, while bathing and during meals. HIH also occurred frequently during physical work, while SAH occurred as frequently during mental work or housework as during hard physical labor. OCVD commonly occurred during sleep or relaxation. The relationship between diurnal variation in stroke and the circadian variation of blood pressure is discussed. The incidence of all three types of strokes during work was higher in the non-aged group (patients under 66 years) than in the aged group (patients over 66 years). HIH and SAH occurred associated with alcohol consumption more frequently in the non-aged group than in the aged group. It is likely that the difference of the time and of the activity during the onset between aged group and non-aged group reflects the difference of life-style between aged and non-aged people.

Effects of insulin and transferrin on the generation of lymphokine-activated killer cells in serum-free medium

We have developed a serum-free medium designated RDSF for the generation of LAK cells based on RD6F medium, which was originally developed as a serum-free medium for the growth of myeloma and hybridoma cells. The cytotoxic activity of LAK cells generated in RDSF against Raji, K562 and oral cancer cells, is 3-4 times that of LAK cells generated in medium containing 10% human type AB serum. RDSF medium consisted of nutrient mixture supplemented with transferrin, 2-aminoethanol, 2-mercaptoethanol, sodium selenite and interleukin-2. In this study, we have found that insulin which has been shown to be the most important polypeptide hormone in serum-free media for animal cells, inhibited the generation of cytotoxic activity of LAK cells cultured from peripheral blood lymphocytes. In addition, we found that transferrin was an essential component for the growth and generation of LAK cells in serum-free culture. These results suggest that RDSF may be useful in adoptive immunotherapy for cancer as well as for studying factors involved in the growth and differentiation of LAK cells.

Androgen-dependent expression of fibroblast growth factor-1 in submaxillary gland of mouse

We have purified a 16,000 dalton protein that stimulates growth of human umbilical cord vein-derived endothelial cells (HUV-EC) from mouse submaxillary glands by using heparin-Sepharose affinity and C4 reverse phase chromatography. The purified molecule was identified as an FGF-1 on the basis of its biological activities, its affinity for heparin and its N-terminal amino-acid sequence. The concentrations of FGF-1 in the submaxillary gland of male or testosterone-treated female mice were about 12 times those of untreated females or castrated males. The 2.3 and 4.1 kb FGF-1 mRNAs were expressed in the glands of male mice older than 4 weeks but not in the glands of female mice. These results suggest that FGF-1 may have important functions for growth, differentiation and development of mouse submaxillary glands, and it may act as an endocrine hormone.

[Comparison of gastrointestinal toxicity of 5-FU derivatives]

Gastrointestinal toxicities of tegafur (FT) and doxifluridine (DFUR) were compared using mouse intestinal enzymes as the marker. Enzyme activities were decreased during repeated administration of these 5-FU derivatives. When the drugs were administrated once a day, the decrease of enzyme activities were almost equal, but when administrated twice a day. DFUR showed greater decrease. Pharmacokinetical analysis revealed faster catabolism of DFUR than FT. In vitro 5-FU formation by GI extract was much higher from DFUR than FT. These data show a good agreement with the fact that the incidence of diarrhea is much higher in DFUR than FT.

[Malignant transformation of benign mixed tumor of lacrimal gland to squamous cell carcinoma 19 years after initial surgery: report of a case]

A case of malignant transformation of benign mixed tumor (pleomorphic adenoma) arising from the right lacrimal gland is reported. A 63-year-old man was referred to our clinic because of visual disturbance and protrusion of the right eye in January, 1989. His past history revealed that he had had a benign mixed tumor of the right lacrimal gland resected 19 years ago. On CT scan, an iso-density lesion homogeneously enhanced with contrast medium was found in the right orbit. This tumor was partially cystic and invaded the cranial cavity. On T1 and T2 weighted MRI, the tumor appeared as an iso-intensity area. At surgery, the tumor was subtotally resected via the combined fronto-orbital approach on February 3, 1990. Histological diagnosis of the tumor was squamous cell carcinoma, and it was construed to be a malignant transformation of mixed tumor of the lacrimal gland. Postoperatively he was placed on a course of external radiation therapy (63 Gy in total) in combination with intra-carotid Cisplatin injection therapy. The first sign of the recurrence was seen as multiple metastatic lesions in both lungs about 4 months after the surgery. In December, 1990, protrusion of the left eye and disturbance of ocular movement became progressively worse. On CT scan, recurrent metastatic tumor was seen in the left orbit and paranasal sinuses. Although additional chemotherapy and irradiation brought about a short period of symptomatic relief he succumbed to pneumonia in April 18, 1990. Metastatic squamous cell carcinoma was confirmed in the lung at autopsy.(ABSTRACT TRUNCATED AT 250 WORDS)

[Intraarterial injection of low molecular weight dextran and urokinase for acute cerebral infarction]

Strategic recanalization of the occluded cerebral vessels has shown promise as a therapy for embolism and thrombosis in the acute stage. A single-dose of urokinase (UK) administered by intravenous and intraarterial routes was usually designed to restore patency of the infarct-related arteries and reperfuse the area of infarction. However, thrombolytic agents which have been available to date may lack resoluvability, limiting the amount of doses, because overdosage may induce hemorrhagic complication. This newly-designed therapy, intraarterial injection of UK-low molecular dextran (LMWD) complex was introduced in order to overcome the danger shown in the previous study. A high-resolvent allows cut-down of urkinase doses. Patients with acute cerebral infarction were selected for treatment with the resolvent if they satisfied the following conditions: 1) up to 79 years old without serious systemic diseases, 2) less than 12 hours from the onset, 3) better than the score of 8 in GCS, 4) no abnormality in CT scan, 5) apparent neurological deficit and 6) responsible pathology in angiography. LMWD of 15ml, UK of 240000IU and 15ml saline-complex was injected as one course at 2.0-2.5ml/min for 11 cases. Recanalization was observed in seven cases of embolism, and lack of reperfusion in five cases of thrombosis. The minimum effective dose was determined as 480000IU of UK in two courses. In terms of time lag from the onset, six hours may be the inferior limit, within which five of six cases (83%) succeeded in the recanalization.(ABSTRACT TRUNCATED AT 250 WORDS)

Synaptic and extra-synaptic distribution of histamine H1-receptors in rat and guinea pig brains

Localization of histamine H1-receptors in subcellular fractions from rat and guinea pig brains was examined in a [3H]mepyramine binding study. Major [3H]mepyramine binding sites with increased specific activities [( 3H]mepyramine binding vs. protein amount) were recovered from P2 fractions from both rat and guinea pig brains by differential centrifugation. Further subfractionation of both rat and guinea pig P2 fractions by a discontinuous sucrose density gradient centrifugation showed the highest recovery of [3H]mepyramine binding with further increased specific activities found in synaptic plasma membrane (SPM) fractions. Minor [3H]mepyramine binding sites with increased specific activities were detected in both rat and guinea pig P3 fractions. [3H]Mepyramine binding sites in SPM and P3 fractions showed identical Kd values in each species. These results indicate that histamine H1-receptors are located not only in synaptic but also in extra-synaptic membranes of both rat and guinea pig brains.

Immuno-cross-reactivity of histidine and dopa decarboxylases

Immuno-cross-reactivity between histidine decarboxylase (HDC) and dopa decarboxylase (DDC) was investigated. By comparing the cDNA sequences of rat HDC with rat and guinea-pig DDCs, we found a region that may possibly be related to the cross-reactivity of anti-rat HDC antibody with guinea-pig DDC. The peptide encoded by this region was synthesized and anti-peptide antibody was prepared. We also purified HDC and DDC homogeniously from fetal rat liver and guinea-pig liver, respectively. On immunoblotting, anti-peptide antibody recognized both rat HDC and guinea-pig DDC. Anti-HDC polyclonal antibody which also recognizes both enzymes detected only rat HDC when it was absorbed by the peptide. This result indicates that this region is responsible for the immuno-cross-reactivity of anti-rat HDC antibody with guinea-pig DDC.

[A case of acute myeloblastic leukemia associated with multiple intracerebral hematomas]

A case of acute myeloblastic leukemia associated with multiple intracerebral hematomas is presented. A 19-year-old woman with a two week's history of mild fever suddenly lost consciousness, and was afflicted right severe hemiparesis, left mild hemiparesis and motor aphasia. A CT scan revealed bilateral thalamic hyperdense lesions and paraventricular small hematoma in the right hemisphere. Hematology showed marked leukocytosis (450,000/mm3), mild anemia and no coagulopathy including disseminated intravascular coagulation syndrome. Cytology showed myeloblasts with positive stain in peroxidase and negative in esterase both in cerebrospinal fluid and blood. These findings indicated M 1 type, myeloblastic leukemia without maturation, according to FAB (French-American-British Co-operative group) classification. CT scan on the second day demonstrated expansion of the hematoma in the right thalamus, and nine brand-new small hematomas in different locations. The patient deteriorated into brain death soon after this examination. The pathology of this case was supposed to be "hyperleukocytosis", which is defined as a leukocyte count greater than 100,000/mm3. Severe leukostasis due both to dense leukocytes and lack of mobility of the myeloblast brought about an increase in permeability because of local impairment of nutrition to the walls of the vessels. As a result, the following histological changes occurred: 1) cellular exudation into Virchow-Robin space, 2) the appearance of leukemic nodule, admixtures of leukemic cells and erythrocytes, 3) mechanical compression of the capillaries and venules by the enlarging mass of the leukemic nodules. CT scan showed these characteristics as follows: 1) multiplicity, 2) small-size, 3) cerebral hemisphere, especially in white matter.(ABSTRACT TRUNCATED AT 250 WORDS)

An alternative method for the isolation of NS-1 hybridomas using cholesterol auxotrophy of NS-1 mouse myeloma cells

We have used the cholesterol auxotrophy of NS-1 mouse myeloma cells as the basis for selecting NS-1 hybridomas. The outgrowth of nascent NS-1 hybridomas in cholesterol-free serum-free medium was 3- to 9-fold more efficient than that in HAT medium and resulted in 3- to 13-times as many antigen-reactive hybridoma wells. This method of hybridoma selection can be applied with any sterol-dependent parent cell line. Hybridomas established under serum-free culture conditions were growth inhibited by fetal calf serum.

[Three-dimensional display of structures and lesions in the brainstem using a personal computer]

The method of three-dimensional reconstruction of structures and lesions in the brainstem was developed by using a personal computer to visualize the affected sites in some cranial nuclei and long tracts. Outlines of brainstem structures and lesions were digitalized manually by tracing the atlas of the human brainstem and CT or MR images. Four outlines of the brainstem, the medulla, lower pons, upper pons and midbrain, and the outlines of any parenchymal structures were taken at every point 2 mm in thickness. These were used as the standard visualization of the atlas. The CT and MRI, which show outlines of the lesions, were taken on the vertical planes to the floor of the fourth ventricle, one of which included the fastigium, at every point 3 to 5 mm in thickness. These two kinds of outlines, taken from the atlas and the CT/MRI, were reconstructed three-dimensionally with commercial 3-D software. It took only 20 to 25 minutes for the digitalization and the 3-D reconstruction. Three-dimensional display of small structures, which were difficult to identify on CT or MRI, and lesions would enable the visualization of their anatomical relations and make possible the detection of the affected sites, not only in the axial but in the longitudinal direction. Correspondence between the affected sites on 3-D and the neurophysiological examinations (ABR, SSEP) confirms that our 3-D method is adequate for use in the anatomical diagnosis of affected sites in any small structure in the brainstem.

[Three-dimensional correlation between auditory brainstem response and auditory tract in hypertensive pontine hematoma]

A three-dimensional reconstructed display using a microcomputer represents the spatial correlation between the nuclei of auditory tract and pontine hematoma. Stereotaxic evacuation of hematoma was performed on seven cases of pontine hemorrhage. By making a comparison between preoperative and postoperative findings of ABR and this display, we examined the effect of the surgical intervention on ABR findings. ABR was recorded according to the standard way (100 dBSL, 2000 click stimuli). Hematoma was drawn on the Atlas of the Human Brainstem and Cerebellar Nuclei by Farhad Afshar. The data plotted on digitizer was inputted and processed under our computer program that enables the brainstem and hematoma visualized and rotated three-dimensionally at our option. The results were as follows: a) ipsilateral dominance in human auditory tract in terms of the origin of ABR waves, b) delayed latency time of wave II which was supposed to be based on an influence upon the ipsilateral superior olivary nucleus, c) that of wave III upon the ipsilateral lateral lemniscus, d) four cases of them showed an improvement of I-III interpeak latency time, which suggested the decompressive effect on caudal aspect of pons.

Congenital vertical pendular nystagmus in sisters

Sisters with congenital vertical nystagmus are described in this report. In these 2 cases, the nystagmus on the electronystagmogram (ENG) showed a pure pendular pattern on forward gaze. Neurological examinations revealed no abnormality except for the nystagmus and visual disturbance. In the elder sister, the ENG showed that the intensity of the nystagmus decreased during eye closure and that there was no response to vertical optokinetic stimulation. We believe that the elder sister is the first case of congenital vertical pendular nystagmus confirmed by neuro-otological and neuro-ophthalmological examinations.

Neurogenic pulmonary edema associated with ruptured intracranial aneurysm: case report

A case of ruptured distal anterior cerebral artery aneurysm associated with neurogenic pulmonary edema is presented. It is suggested that this association should not be accepted as a "taboo" for radical intervention followed by a proper management of ventilation with positive end-expiratory pressure to maintain the anesthetic condition. Cardiorespiratory control is essential in cases of pulmonary edema with ruptured aneurysm. Decompression and evacuation of blood clot surrounding the hypothalamus could subdue the hyperadrenosympathetic discharge that may cause neurogenic pulmonary edema.

Monoclonal IgM-secreting neoplasms. Clinical and morphologic heterogeneity

Two patients with monoclonal IgM-secreting neoplasms are presented. Though both patients could be diagnosed as Waldenström's macroglobulinemia, the clinicopathologic features were quite contrastive. Most neoplastic cells in Case 1 showed lymphocytic morphology with rather leukemic process, while those in Case 2 were highly polymorphic with solid proliferation. The clinical and morphologic heterogeneity in these cases and cases in the literature is discussed, and the possible requirement to establish a system for the subclassification of IgM-secreting neoplasms is insisted.

Moyamoya disease associated with intracranial aneurysms

A case of moyamoya disease associated with multiple intracranial aneurysms is reported. The aneurysms were located at the bifurcation of the basilar artery and at the precommunicating segment of the right posterior-cerebral artery. They were found to be unruptured and clipped successfully through a right frontotemporal craniotomy. Outcome of the operation was satisfactory. We propose the operative indication for these cases on the basis of operative and radiological findings, and also discuss characteristic aspects of this disease.

[Multiple malignant intracerebral schwannomas in von Recklinghausen's disease--report of a case]

Intracerebral schwannoma is very rare, and only nine cases of solitary intracerebral schwannoma have been reported since the first description by Gibson et al, in 1966. This report is the first case of multiple intracerebral schwannomas in Japan. Intracranial extracerebral schwannomas in von Recklinghausen's disease are sometimes encountered, but intracerebral ones have not been discovered. A case of multiple intracerebral schwannomas associated with von Recklinghausen's disease is reported in a 23-year-old male. He had been healthy until January 1979 when he was pointed out an abnormal shadow on chest roentgenogram. Although thoracic tumor revealed schwannoma in histological examination of surgical specimen, it transformed to malignant one during next 15 months. In July 1980, he complained of severe headache, vertigo, nausea and vomiting, and bilateral papilledema was proved. He was admitted to our clinic on August 8, 1980. Two large intracerebellar and four intracerebral tumors were revealed by computed tomography (CT). Angiography demonstrated avascular masses. The cerebellar tumors were totally extirpated on August 12, 1980. Histological diagnosis of the removed tumors approved malignant schwannoma, but their correlation to the chest tumor was unclear. Follow-up CT scans demonstrated that the supratentorial tumors increased in size during about three months. The chest tumor also increases in size. He died on November 12, 1980, but autopsy was not done. Pathogenesis of intracerebral schwannomas in this case is controversial, and we suggest that it is (1) multiple schwannomas in von Recklinghausen's disease with malignant transformation, or (2) metastasis from the chest tumor. But the conclusion remains unclear.