A prospective cohort study of sensorineural hearing loss associated with Kawasaki disease

AIM

About 60 cases of sensorineural hearing loss (HL) have been reported in patients with Kawasaki disease (KD), but the current estimate of its prevalence is uncertain. The present study aimed to determine the prevalence and risk factors of sensorineural HL associated with KD.

METHODS

The present, prospective cohort study, conducted from May 2019 to May 2020, evaluated patients with a diagnosis of KD who received the initial therapy and underwent two auditory brainstem response (ABR) tests. HL was defined as a threshold of 40 dB or more, and borderline hearing was defined as a threshold of 30 dB.

RESULTS

In total, 107 patients were enrolled, and 75 underwent two ABR tests. Thirty-one patients (30.0%) received prednisolone with their initial intravenous immune globulin and acetylsalicylic acid therapy. HL was present in only one patient who had congenital conductive HL. Five patients had borderline hearing but had normal hearing behavior. There was no significant difference between the patients with normal hearing and those with borderline hearing in terms of the clinical variables.

CONCLUSIONS

In Japan, the prevalence of sensorineural HL after KD is not high. It may therefore be unnecessary to perform routine hearing tests for all patients with KD.

NAME OF TRIAL REGISTER

Association between Kawasaki Disease and Sensorineural Hearing Loss.

CLINICAL TRIAL REGISTRATION NUMBER

UMIN000037019 (the date of registration: June 11, 2019).

Cerebral blood flow abnormalities with central sparing on arterial spin labeling in mild encephalopathy associated with excitotoxicity: a case report

BACKGROUND

Acute encephalopathy with biphasic seizures and late reduced diffusion (AESD) and mild encephalopathy associated with excitotoxicity (MEEX) are the most frequent acute encephalopathies in pediatric patients in Japan. AESD typically presents with biphasic seizures and delayed reduced diffusion in the subcortical area, called bright tree appearance (BTA), on radiological examination. In patients with AESD, arterial spin labeling (ASL) shows decreased cerebral blood flow (CBF) in the hyperacute stage and increased CBF in the acute stage, suggesting the usefulness of ASL for the early diagnosis of AESD. Additionally, proton magnetic resonance spectroscopy (MRS) shows elevated glutamate (Glu) and glutamine (Gln) in AESD. MEEX is a group of mild encephalopathies with transient elevation of Gln on MRS similar to that in AESD; however, MEEX does not include any clinical biphasic course or abnormalities, including BTA on diffusion-weighted imaging. Although the usefulness of ASL for AESD has been reported, there are no reports for patients with MEEX. In this study, we report our experience with a 4-year-old girl diagnosed with MEEX who showed unique findings on ASL.

CASE PRESENTATION

The patient was a 4-year-old girl admitted to the emergency room with febrile status epilepticus. Considering the possibility of AESD, vitamin therapy was initiated. ASL-MR imaging (MRI) of the brain performed on the second day showed increased blood flow in the frontal, temporal, and occipital regions with spared central sulcus, which indicated AESD with central sparing. The patient was diagnosed with AESD, and the treatment included pulse steroid therapy and immunoglobulin therapy from day 3. The patient remained mildly unconscious but gradually became conscious by day 7 with no seizures. Brain MRI performed on day 8 did not show any characteristic AESD findings, such as BTA. Furthermore, MRS showed elevated Gln, which, along with the clinical course, led to the diagnosis of MEEX. The patient was discharged on day 16 without obvious sequelae.

CONCLUSIONS

ASL may be useful in the early diagnosis of MEEX as well as AESD, facilitating early intervention.

Hyperspectroscopic imager for baby fibers

Hyperspectral imaging system for diagnosing digestive diseases was newly developed in order to obtain information on pathology beyond morphology of lesions. In order to guide light reflected from a lesion, a baby fiber, which can be inserted in a forceps channel of the electronic endoscope, was also developed. The performance of the system was evaluated by animal experiment. Obtained hyperspectral data were found to have sufficient quality endurable to practical use. Harmful phenomena to a living body were not observed within the experiment. It was considered from the animal experiment that the present system could be practically used for humans.

229 DERIVATION OF PRESUMPTIVE GONOCYTES IN VITRO FROM PRIMATE EMBRYONIC STEM CELLS

Embryonic stem cells (ESCs) of nonhuman primates are important for research into human gametogenesis, because of similarities between the embryos and fetuses of nonhuman primates and those of humans. Recently, the formation of germ cells from mouse ESCs in vitro has been reported. In this study, we established cynomolgus monkey ES (cyES) cell lines and attempted to induce their differentiation into germ cells in order to obtain further information on the development of primate germ cells by observing the transcripts of some markers reported as specific for germ cells. CyES cell lines were established using blastocysts produced by intracytoplasmic sperm injection (ICSI). For inducing superovulation, females were treated with 25 IU kg-1 pregnant mare serum gonadotropin once a day for 9 days, followed by 400 IU kg-1 hCG. Oocytes were collected at 40 h after injection of hCG. After sperm injection, embryos were cultured in mCMRL medium to the blastocyst stage. For cyES cell establishment, inner cell masses (ICMs) were isolated by immunosurgery. The ESC colonies developed at about 10 days after ICM plating, and 3 cell lines were successfully established (3/11; 27.3%). All cell lines expressed Oct3/4, SSEA-4, and ALP activity. These ESCs formed teratomas containing 3 different embryonic layers when injected into SCID mice. And the cells could be passaged over 50 times without losing their original properties. To observe in vitro gametogenesis, we attempted to induce differentiation by non-adherent conditions. When cyES cells differentiated spontaneously, the aggregated structures (i.e. embryoid bodies; EBs) accumulated vasa, the expression of which is restricted to germ cells, and some meiotic markers such as dmc1 and sycp1 that exist only in synaptonemal complexes in meiosis. The existence of these markers was also confirmed by immunocytochemistry on cryosections. Interestingly, these products expressed oct4 and nanog again at Day 16, though the expression of both genes diminished at once with onset of differentiation. In vivo, it is reported that vasa, oct4, and nanog are expressed in migrating PGCs, posibly throughout the development of germ cells into spermatocytes/oocytes. Given the results obtained with the meiotic markers, it is possible that developing germ cells such as PGCs or gonocytes could be formed in cynomolgus EBs as in previous cases with mouse or human EBs. These results demonstrate that cyES cells might contribute to putative germ cells in vitro by differentiating into EBs and could be used as a model for studying mechanisms of germ cell development. This study was supported by a Grant-in-Aid for the 21st Century COE Program of the Japan Mext and by a grant for the Wakayama Prefecture Collaboration of Regional Entities for the Advancement of Technology Excellence of the JST.

[Mitral valvuloplasty utilizing a posterior leaflet patch for healed infective endocarditis; report of a case]

A 63-year-old man was diagnosed as having grade IV mitral regurgitation (MR). Intraoperative examination revealed perforation (13x7 mm) of the anterior mitral leaflet (AML) and prolapse of the posterior mitral leaflet (PML). The prolapsing part of the PML was resected as a rectangle and the AML perforation was covered with this resected PML patch. A Carpentier-Edwards rigid ring (30 mm) was used to secure the mitral valve annulus after suturing the PML. The patient had an uneventful course after surgery and postoperative echocardiography showed no regurgitation.

39 DEVELOPMENTAL COMPETENCE OF RECONSTRUCTED EMBRYOS PRODUCED BY NUCLEAR TRANSFER BETWEEN CYNOMOLGUS MONKEY FIBROBLAST CELLS AND RABBIT OOCYTES

Interspecies nuclear transfer has been used as an invaluable tool for studying nucleus-cytoplasm interactions and it may also be used for rescuing endangered species whose oocytes are difficult to obtain. In this study, we investigated interaction of the cynomolgus monkey cell as a nuclear donor with the rabbit oocyte as a host cytoplasm. Whole cynomolgus fibroblast cells were injected into the rabbit enucleated oocytes (cynomolgus-rabbit cloned embryos) and cultured in TCM-199 and RPMI 1640 culture media. Rabbit-rabbit cloned embryos we used as control in this study. Karyotype analyses confirmed that genetic material of blastocysts was derived from the cynomolgus donor cells at blastocyst stage. Mitochondrial constitution analysis of the cynomolgus-rabbit cloned embryos indicated that mitochondria from both donor cells and enucleated oocytes coexisted. After culture for 168 h post-nuclear transfer, all cynomolgus-rabbit cloned embryos in TCM-199 were arrested at the 8-cell stage, but some of them developed to the blastocyst stage in RPMI 1640 (11/59, 18.6%). In this experiment, the nutrition requirement in vitro and the cleavage rate at each 24 h were examined. When TCM-199 was supplemented with lactate, some of these embryos developed to the blastocyst stage (15.3%, 2/13). This means that cynomolgus-rabbit cloned embryos might be controlled by the donor nucleus even in these early developmental stages. However, the timing of cleavage of cynomolgus-rabbit cloned embryos is very similar to that of the rabbit-rabbit cloned embryos. Time of cleavage may depend on the protein accumulated in the cytoplasm. In the prolonged culture of reconstructed embryos on feeder cells, adhesion cells were observed. These cells are also very similar to the cells derived from cynomolgus embryos by the same method. Our results suggest that: (1) a cynomolgus nucleus can co-ordinate with rabbit oocyte cytoplasm in early embryo development, (2) the 8- to 16-cell stage block in the cynomolgus-rabbit cloned embryos may due to the same reason as that in the cynomolgus embryos, and (3) ooplasmic factors that control time of cleavage are highly conservative between the species.

207 ESTABILSHMENT OF CYNOMOLGUS MONKEY EMBRYONIC STEM CELL LINES AND CONFIRMATION OF THE POSSIBILITY FOR GERMINAL COMPETENCY

Embryonic stem cells (ESCs) of nonhuman primate are important tools for human gametogenesis research. Generally, ESCs, embryos, and fetuses of nonhuman primates are similar to these of human. Recently, germ cell formation of mouse ESCs in vitro has been reported. In this study, we established new cynomolgus monkey ES (cyES) lines and determined germinal competency by assessing expression of mRNA markers. CyES lines were established using blastocysts produced by intracytoplasmic sperm injection (ICSI). For inducing super-ovulation, females were treated with 25 IU/kg pregnant mare serum gonadotropin (PMSG) once a day for 9 days, followed by 400 IU/kg hCG. Oocytes were collected 40 h after injection of hCG. After sperm injection, embryos were cultured in mCMRL medium to the blastocyst stage. For ES line establishment, inner cell masses (ICMs) were isolated by immunosurgery. ESC colonies emerged at about 10 days after ICM plating; three cyES cell lines were successfully obtained (3/11; 27.3%). We characterized these lines by immunocytochemistry for Oct-3/4, SSEA-3, and SSEA-4, which are diagnostic markers for primate ESCs, and by assay for alkaline phosphatase (ALP) activity. All cell lines expressed Oct-3/4, SSEA-4 and ALP activity. The previously reported SSEA-3 weak expression in cyES cells was not observed. These lines differentiated spontaneously when they were replaced in non-adherent culture (embryoid body: EB) or injected into SCID mice subcutaneously. To assess germ cell competency in vitro, we analyzed for the presence of vasa mRNA which shows a restricted expression pattern to germ cell formation, and DMC1 and SYCP1 which show specific existence on synaptonema complex in meiosis. Detection of these germ cell markers was performed by RT-PCR with total cDNA from ESCs and EBs. Nanog mRNA was detected only in ESCs. Oct-4 was detected in gonadal tissue of both sexes, ESCs, and EBs. Vasa was expressed in testis, but not in ESCs or somatic cells. Interestingly, we recognized weak expression of Vasa in Day 12-16 EBs. DMC1 and SYCP1 as meiosis markers were not detected. Because Oct-4 and Vasa mRNA are transcribed simultaneously, similar to that in the early part of gametogenesis such as the latter period of primordial germ cell (PGC) migration, PGC formation in cynomolgus EBs could occurr as in some cases of mouse or human EBs previously reported. Although detailed properties such as the functions of these Vasa-positive cells have not been confirmed, these results demonstrate that cyES cells obtained in the current study might contribute to putative germ cells in vitro by differentiating to EBs. This study was supported by a Grant-in-Aid for the 21st Century COE Program of the Japan Mext and by a grant for the Wakayama Prefecture Collaboration of Regional Entities for the Advancement of Technology Excellence of the JST.

Sixteen-year experience with 1,000 heart transplants at UCLA

1. The consecutive pre- and post-1994 eras have demonstrated improved survival for all age groups. This is linked to improved preservation methods, surgical technique and immunosuppression agents. 2. The use of marginal donor hearts for Status I and alternate elderly patients has followed the model of matching donor and recipient risk without affecting patient outcome and minimized the use of implantable assist devices. 3. A donor history of systemic gram-negative infection, hypertension, or traumatic intracranial bleeds was an important marker for risk. Younger age and shorter ischemia time could compensate for other hazards. 4. Heart transplantation in carefully selected elderly recipients yielded clinical results similar to those of younger patients with less rejection. 5. An adult alternate recipient list proved useful to prevent diversion of standard donors away from younger recipients. 6. Retransplantation for TCAD is acceptable but much less satisfactory for acute graft failure. 7. Trends show an increase in the use of implantable devices; refinement in technology for mechanical assist and replacement is forthcoming.

Histopathologic analysis of angiogenic factors in localized renal cell carcinoma: the influence of neoadjuvant treatment

BACKGROUND

This study was conducted in order to clarify whether histopathologic analysis of factor thymidine phosphorylase (TP) and Factor VIII could be a useful predictor of postoperative recurrence in localized renal cell carcinoma. Therefore, the relationship between tumor infiltrated lymphocytes (TIL) and both TP and Factor VIII was studied.

METHOD

Of the 71 patients who underwent surgery, 54 patients had no neoadjuvant therapy (group 1), 10 patients were preoperatively administered IFN-gamma (group 2), and the remaining seven patients preoperatively received IFN-gamma and transarterial embolization (group 3). Both TP and Factor VIII immunostaining were performed on formalin-fixed, paraffin-embedded archival tissue from 71 renal cell carcinoma specimens, while TIL immunostaining was performed on frozen sections. Positive immunostaining was quantitatively scored by a computer-assisted digital image analysis. For TIL, positive results were semiquantitatively scored.

RESULTS

A significant difference in the recurrence-free rate was recognized for Groups 1, 2 and 3 (P < 0.05). Therefore, the median TP-positive rate (PR), VIII-PR, number of microvessels and positive mean vascular area levels were investigated, between the recurrence cases (n = 6) and the recurrence-free cases (n = 11). Only the TP-PR levels showed a significant difference among them (P = 0.044). In regards to the neoadjuvant cases, a significant correlation was observed between both VIII-PR and CD4 (r = 0.815) as well as between VIII-PR and CD11b (r = 0.756).

CONCLUSION

There was no clear evidence that the neoadjuvant treatment would increase the recurrence-free survival in patients with localized renal cell carcinoma. TP-PR might be a predictor of postoperative recurrence in patients with localized renal cell carcinoma.

Effects of mixed administration of glucose and fat emulsion on the liver of rats undergoing hepatopancreatectomy

To prevent the development of liver failure after simultaneous massive resection of the liver and pancreas, we examined whether fat emulsion could be used as an energy source during postoperative transfusion. Using rats, the following four groups were prepared: the simple laparotomy group (S group), 68% hepatectomy group (H group), 90% pancreatectomy group (P group) and 68% hepatectomy + 90% pancreatectomy group (HP group). A constant total calorie level and transfusion dose were used. Three kinds of transfusions with different glucose-to-fat emulsion caloric ratios, that is: 75% fat emulsion (of the total calorie level) + 25% glucose (75L), 50% fat emulsion + 50% glucose (50L) and 25% fat emulsion + 75% glucose + 1 unit/5 g glucose of insulin (25L), were continuously administered for 48 hours, and the effects of these transfusions on the survival rate and liver were examined. After 75L administration, survival rates in the H group and HP group were significantly lower than those in the S group and P group. After administration of 50L, survival rates did not significantly differ among the four groups. After 25L administration, the survival rate in the HP group was significantly lower than that in other groups. In the HP group, the survival rate after 50L administration was the highest. However, necrosis was observed in a portion of the hepatic lobule, while the blood aspartate aminotransferase (AST) level was increased. After 25L administration, hepatocellular mitochondrial swelling and degeneration were noted in the HP group; furthermore, the blood total protein level was decreased. These results showed that the post-operative administration of fat emulsion at a percentage of 50% of the total calorie level caused partial hepatocellular necrosis in the HP group, but improved the survival rate.

Cyclophosphamide and 5-fluorouracil act synergistically in ovarian clear cell adenocarcinoma cells

Chemosensitivity to the drugs plays a crucial role in the treatment of ovarian cancer. In this study, we evaluate the cytotoxicity of chemotherapeutic agents in six ovarian cancer cell lines; four clear cell adenocarcinoma and two serous papillary adenocarcinoma, using seven single drugs and seven sets of drug combinations with tetrazolium-based semiautomated colorimetric (MTT) assay. The drug concentration which produced 50% growth inhibition (IC50) of cisplatin was within clinically achievable range in five cell lines. The area under the curve (AUC) at IC50 of cyclophosphamide was below the clinically achievable AUC in two serous papillary cell lines. Paclitaxel was more effective in clear cells than serous papillary cells. The intensification of cytotoxicity was observed in the combinations of paclitaxel and cisplatin, and cyclophosphamide and cisplatin or 5-fluorouracil irrespective of histopathological characteristics of the original tumor. Our results indicate that ovarian cancer cell lines respond to chemotherapeutic agents heterogeneously depending upon histopathological features, indicating individualized regimens may improve survival in ovarian cancer patients.

[Pulmonary Nocardia otitidiscaviarum infection in an immunocompetent host]

A rare case of pulmonary Nocardia otitidiscaviarum (N. otitidiscaviarum) was encountered in an immunocompetent host. A 74-year-old man was admitted to our hospital with a high fever and a productive cough. His chest radiograph and CT scan revealed infiltrative shadows in the right middle and lower lung fields. Although several antibiotics (third-generation cephalosporin, minocycline, imipenem) were administered, the fever and cough persisted, and C-reactive protein remained elevated. Repeated sputum cultures showed normal flora, so a transbronchial lung biopsy and bronchoalveolar lavage (BAL) were performed bronchoscopically at the right S5. The BAL fluid contained acid-fast, branching filamentous structures. The microorganism was identified as N. otitidiscaviarum by the Research Center for Pathogenic Fungi and Microbial Toxicoses (Chiba University). Trimethoprim-sulfamethoxazole was therefore administered, but the fever continued to rise daily, and C-reactive protein remained elevated. This isolated N. otitidiscaviarum showed resistance to multiple antimicrobial agents in vitro when examined by the disk diffusion method, and so, on the basis of the antibiogram, the patient was treated with clarithromycin (oral, 600 mg/day) plus amikacin (400 mg/day), which proved successful. Testing for pulmonary nocardiosis should be added to the differential diagnosis procedures for refractory pneumonia as an opportunistic infection and for community-acquired pneumonia.

Cytoreductive surgery with liver-involved renal cell carcinoma

The purpose of this study was to demonstrate the benefits of cytoreductive surgery for renal cell carcinomas that also involve the liver. Between 1994 and 1997, four patients with renal cell carcinoma with liver involvement were surgically treated with nephrectomy and hepatectomy. Two of them underwent a simultaneous hepatectomy and nephrectomy (group 1), and the remaining two patients underwent a hepatectomy after a nephrectomy and had a diagnosis of postoperative recurrence (group 2). Two patients, one from each group, died of multiple bone metastasis and lung metastasis 30 months and 12 months after the hepatectomy; the second patient from group 1 died 40 months after the first operation due to gastrointestinal hemorrhaging. The second patient from group 2 displayed no evidence of recurrence 18 months after the second surgical procedure. The survival rates for these patients were 66% and 33% at 1 and 3 years, respectively. Autopsy studies revealed that one patient from group 2 had a local recurrence in the liver while the other two patients from group 1 did not. Our results suggested that a progressive approach may therefore be useful for patients demonstrating renal cell carcinoma where there is liver involvement.

Vacuolar hepatocyte degeneration induced by infusion of 20% glucose solution with insulin after hepatopancreatectomy in rats

To investigate the causes of hepatic dysfunction after extensive resection of the liver together with pancreatectomy, rats were subjected to sham operation, to 68% hepatectomy alone, to 90% pancreatectomy alone, or to 68% hepatectomy combined with 90% pancreatectomy (hepatopancreatectomy). Solutions of 5% or 20% glucose were infused post-operatively for 48 h at a constant rate (250 ml/kg body weight/day) under fasting conditions. To improve the survival rates of pancreatectomized and hepatopancreatectomized rats given 20% glucose, it was necessary to use insulin. In hepatopancreatectomized rats, infusion of 20% glucose with insulin (1 U/5 g glucose) induced prominent hepatocyte vacuolar degeneration and mitochondrial swelling, associated with reduced hepatic protein content. The severity of histological changes was proportional to the insulin dose and the activity of hepatic glucokinase, a key glycolytic enzyme. were observed in These histological changes pancreatectomized rats albeit in a milder form, but not in sham-operated or hepatectomized rats given 20% glucose nor in any rats given 5% glucose. Our results suggest that hepatopancreatectomy followed post-operatively by a high glucose load and exogenously administered insulin enhances the development of hepatocyte swelling.

Recurrent idiopathic iridocyclitis after autologous peripheral blood stem-cell transplantation followed by G-CSF administration for acute lymphoblastic leukemia

We describe a patient who experienced a recurrence of idiopathic iridocyclitis on day 12 after autologous peripheral blood stem-cell transplantation (auto-PBSCT) followed by G-CSF administration for acute lymphoblastic leukemia (ALL). Autologous SCT has been reported to be effective and safe in achieving dose intensification of chemotherapeutic drugs for the treatment of hematopoietic malignancies, but its therapeutic effect on autoimmune diseases is not definite. The findings from the present case suggest that auto-PBSCT followed by G-CSF administration for patients with a history of some kind of autoimmune disorders may induce exacerbation or recurrence of its symptoms after hematopoietic recovery.

Induction of N-hydroxycinnamoyltyramine synthesis and tyramine N-hydroxycinnamoyltransferase (THT) activity by wounding in maize leaves

Both N-p-coumaroyl- and N-feruloyltyramine accumulated in response to wounding in leaf segments of maize. The amount of N-hydroxycinnamoyltyramines started to increase 3-6 h after wounding and peaked at 12 h. Thereafter, the amount of N-p-coumaroyltyramine decreased rapidly, while the N-feruloyltyramine content remained at a high level. The accumulation of N-hydroxycinnamoyltyramines was accompanied by an increase in the tyramine N-hydroxycinnamoyltransferase (THT) activity. This increase was initially detected 3 h after wounding and reached a maximum at 36 h, the level of activity being 40 and 11 times that in the leaves before wounding and in the control leaves, respectively. Partial purification of THT from wounded leaves by (NH4)2SO4 precipitation and subsequent two steps of anion-exchange chromatography resulted in a 12.5-fold increase in specific activity. Kinetic studies with this partially purified enzyme revealed that the best substrates were tyramine and feruloyl-CoA, although tryptamine and sinapoyl-CoA also efficiently served as substrates. The apparent native molecular weight of the enzyme was determined by gel filtration as 40 kDa.

The University of California at Los Angeles experience in heart transplantation

In the last decade, the number of patients undergoing heart transplant has steadily increased as a result of expanding indications for this procedure. The limitation on the number of transplants performed has been the number of donor organs available. At UCLA, 900 heart transplant procedures have been performed from 1984-1998. Since 1991, the percent of patients free from rejection and infection in the first year after transplant was 70% and 73%, respectively. Actuarial one-, 3-, and 5-year survival rates are 84%, 76%, and 72%, respectively. Survival of patients aged 60 years and over (n = 105) was comparable to that of patients under age 60. We have been pursuing corticosteroid-free immunosuppression, which has led to a decrease in infection complications. Our work with pravastatin early after transplantation has led to a decrease in clinically severe rejection episodes, which has translated into improved survival. Pravastatin also appears to decrease the development of transplant coronary artery disease and appears to have an adjunct immunosuppressive effect in our heart transplant patients on CsA-based immunosuppression. We have also demonstrated benefit of cardiac rehabilitation early after transplant which should therefore be considered as standard postoperative care. Finally, we have participated and led the multicenter mycophenolate study in demonstrating this drug's effectiveness in improved outcomes in primary heart transplant recipients. Future studies include the use of Rapamycin and interleukin-2 receptor blockers which have been demonstrated in kidney transplantation to significantly reduce rejection. Our program is committed to seek better ways to improve outcome and the quality of life of our heart transplant patients.

[The effect of 5-HT 2 antagonist for urinary frequency symptom on diabetes mellitus patients]

17 cases of patients with diabetes mellitus who had urinary frequency symptom for which anti-cholinergic agents proved ineffective were given Sarpogrelate Hydrochloride (Anplag), a selective 5-HT 2 receptor antagonist. Efficacy was judged using IPSS and QOL scores after 2 weeks medications, these showed that all cases had improved their urinary frequency during the days as well as the night. This was especially true for the QOL score. One time urinary volume markedly increased, but there was no statistical significance after medication in maximum flow rate and residual urine. At the same time, a separate group of 14 mainly BPH cases did not improve entirely. It is believed that reaction in the detrusor muscle with hyperreflexia of diabetes mellitus patients can reach 5-HT, and its reaction is believed to reach via the 5-HT 2 receptor. This paper is a first clinical report of making use of 5-HT 2 antagonist as hyperactive detrusor on diabetes mellitus patients.

[Immunohistochemical study of p53 and Ki-67 antigen expression in bladder carcinoma]

We examined the relationship between the expression of mutant p53 and Ki-67 antigens in urinary bladder transitional cell carcinoma and the pathological and clinical findings. Tissues were obtained from 28 patients with bladder carcinoma who underwent total or partial cystectomy. An ABC immunostaining method and two primary antibodies (DO-7 and MIB-1 antibodies) were used. The percentages of p53 and Ki-67 antigen-positive cells to the total number of cells were regarded as the p53 and Ki-67 labeling indices (LI) respectively. There were no statistically significant correlations between p53 LI and the histological grade or stage, although p53 LI increased slightly in the high grade and high stage group. There was a statistically significant correlation between Ki-67 LI and the histological grade and stage (p < 0.05). The correlation between p53 LI and Ki-67 LI was linear. Some cases had a p53 LI below the mean even though the Ki-67 LI was higher. The clinical course was characteristic of superficial bladder carcinoma initially, but progressed to invasive bladder carcinoma over the next several years. These results suggest that even cases initially diagnosed as superficial bladder carcinoma with a low p53 LI may progress to invasive bladder carcinoma in subsequent years. Therefore, it is important that the patient be followed-up.

A controlled trial of exercise rehabilitation after heart transplantation

BACKGROUND

In patients who have received a cardiac transplant, the denervated donor heart responds abnormally to exercise and exercise tolerance is reduced. The role of physical exercise in the treatment of patients who have undergone cardiac transplantation has not been determined. We assessed the effects of training on the capacity for exercise early after cardiac transplantation.

METHODS

Twenty-seven patients who were discharged within two weeks after receiving a heart transplant were randomly assigned to participate in a six-month structured cardiac-rehabilitation program (exercise group, 14 patients) or to undergo unstructured therapy at home (control group, 13 patients). Each patient in the exercise group underwent an individualized program of muscular-strength and aerobic training under the guidance of a physical therapist, whereas control patients received no formal exercise training. Cardiopulmonary stress testing was performed at base line (within one month after heart transplantation) and six months later.

RESULTS

As compared with the control group, the exercise group had significantly greater increases in peak oxygen consumption (mean increase, 4.4 ml per kilogram of body weight per minute [49 percent] vs. 1.9 ml per kilogram per minute [18 percent]; P=0.01) and workload (mean increase, 35 W [59 percent] vs. 12 W [18 percent]; P=0.01) and a greater reduction in the ventilatory equivalent for carbon dioxide (mean decrease, 13 [20 percent] vs. 6 [11 percent]; P=0.02). The mean dose of prednisone, the number of patients taking antihypertensive medications, the average number of episodes of rejection and of infection during the study period, and weight gain did not differ significantly between the groups.

CONCLUSIONS

When initiated early after cardiac transplantation, exercise training increases the capacity for physical work.

Electron microscopic study of the penile plaques and adjacent corpora cavernosa in Peyronie's disease

BACKGROUND

We conducted ultrastructural studies to clarify the fine structure of penile plaques and adjacent corpora cavernosa, and the causative basis for the process, in Peyronie's disease.

METHODS

Penile plaques and adjacent corpora cavernosa were obtained during surgical extirpation from 5 patients with Peyronie's disease. Control tissues from the tunica albuginea and adjacent corpora cavernosa were obtained at penile amputation from 2 patients with penile cancer. Prepared tissues were examined by using electron microscopy.

RESULTS

Penile plaques were composed of collagen fibrils, amorphous particulate material, and fibroblasts in all patients. In 1 of 5 patients, myofibroblasts were found in the border area between the lesion and underlying structures. Smooth-muscle cells and endothelial cells resembling myofibroblasts were noted in adjacent corpora cavernosa. In this patient, the plaque progressively enlarged, and was removed within 1 year of onset of the induration.

CONCLUSIONS

Fibromatosis in Peyronie's disease involves both fibroblasts and myofibroblasts, which undergo sclerosis in some phase. In addition, smooth-muscle cells and endothelial cells in the adjacent corpora cavernosa may be incorporated in the fibromatosis.

Pretransplant panel reactive-antibody screens. Are they truly a marker for poor outcome after cardiac transplantation?

BACKGROUND

The effect of pretransplant sensitization on outcome after cardiac transplant has been controversial. Sensitization, defined as a positive panel-reactive antibody (PRA) screen in patients awaiting transplant, represents circulating antibodies to a random panel of donor lymphocytes (usually T lymphocytes). The significance of pretransplant circulating antibodies to B lymphocytes has not been reported, and many centers disregard its use.

METHODS AND RESULTS

We retrospectively reviewed the pretransplant PRA screens for 311 patients who underwent cardiac transplant at our institution. The PRA screen was performed by use of the lymphocytotoxic technique treated with dithiothreitol to remove IgM autoantibodies. Patients with PRA > or = 11% against T or B lymphocytes had significantly lower 3-year survival (T lymphocytes, 39%; B lymphocytes, 56%) than those patients with PRA = 0% and PRA = 1% to 10% (T lymphocytes, 76% and 78%; B lymphocytes, 78% and 74%, respectively) (P < .001). For this high-risk group, the rejection episode tended to occur earlier than in those patients with PRA = 0% and PRA = 1% to 10% (T lymphocytes, 2.3 versus 4.0 and 3.8 months; B lymphocytes, 2.1 versus 4.1 and 3.4 months, respectively), and there were more clinically severe rejections that required OKT3 therapy.

CONCLUSIONS

Cardiac transplant patients with pretransplant T- and/or B-lymphocyte PRA > or = 11% despite negative donor-specific crossmatch at the time of transplant appear to have earlier and more severe rejection with significantly lower survival after transplant surgery. Modification of immunosuppression in these high-risk patients may be warranted.

[A case study of metastatic renal cell carcinoma in lungs showing complete response to continuous subcutaneous injection of interferon alpha and gamma]

Previously, we reported a case of complete response (CR) of metastatic renal cell carcinoma with inhalant interferon-gamma. This inhalant therapy was considered effective against metastatic lung hilar tumors. On the other hand, metastatic tumors of the peripheral lung field tumor did not respond to the inhalation therapy. We report, a case of metastatic renal cell carcinoma in peripheral lungs showing complete response to continuous subcutaneous administration of interferon alpha and gamma. A 53-year-old woman was admitted to our hospital because of a large palpable mass in the left upper quadrant in March, 1994. Computerized tomographic (CT) scan disclosed a huge renal tumor. To reduce the tumor size, transarterial embolization, and subcutaneous administration of interferon-gamma were performed. In April 1994, the tumor was completely excised. In the post-operative course, multiple metastases were recognized in the lower peripheral lung field, subcutaneous administration of IFN-gamma and inhalation of IFN-gamma were begun, but the tumor size increased in October 1994. She underwent continuous subcutaneous administration of IFN-alpha and gamma. Three months later, the lung tumor disappeared. She has remained tumor-free as of October 1995. We concluded that this therapy may be effective against metastatic renal cell carcinoma in the lungs.

[Immunological effect of recombinant interferon-gamma on tumor infiltrating lymphocytes of renal cell carcinoma--relationship with clinical stage]

We studied the relationship between clinical stage and tumor infiltrating lymphocytes (TIL) in 26 cases of renal cell carcinoma. In 10 patients, interferon-gamma (IFN-gamma) was administered preoperatively (administration group); 5 patients had low stage (Robson < or = I), and the remaining 5 patients had high stage (Robson > or = II) tumors. The other 16 patients underwent nephrectomy alone without preoperative IFN administration (control group); 11 patients had low stage, and the remaining 5 patients had high stage tumors. Immunohistochemical studies of tumor infiltrating lymphocytes in renal cell carcinoma showed a significantly high incidence of CD3, CD8, CD11b and ICAM-1 in the administration group, while CD4, LFA-1 and Ber-MAC3 were increased without significance (p < 0.05). Concerning clinical stage (Robson), a significant increase in CD3, CD8, CD11b and ICAM-1 was observed in the patients with high-stage tumors in the administration group compared to those in the control group (p < 0.05). This suggested that TIL could be changed by preoperative administration of IFN-gamma.

Signal transduction by IgG receptors induces calcium mobilization, but not histamine release, in the human basophilic cell line KU812F

Human blood basophils selectively express Fc gamma RII (CDw32) among IgG receptor subtypes, but its functional role in allergic reactions remains unknown. Using the human basophilic leukemia cell line KU812F as a model system, we investigated cellular signaling events mediated through IgG receptor stimulation. KU812F cells express Fc gamma RII on their surface. mRNAs for both Fc gamma RIIA and IIB subtypes were detected by reverse transcriptase-PCR analysis. In this cell line, Fc gamma RII stimulation induced mobilization of free intracellular calcium and actin polymerization. Yet, no significant histamine release was observed, nor did blood basophils stimulated by anti-Fc gamma RII monoclonal antibody IV.3 and by a secondary antibody release histamine. These data indicate that Fc gamma RII stimulation induces cellular signaling events such as calcium mobilization in human basophils. However, these events do not lead to histamine release.

Interruption of hepatic arterial blood flow after resection of pancreaticobiliary carcinoma

BACKGROUND/AIMS

We reviewed 17 cases of patients with interrupted hepatic arterial blood flow to determine the effect of such an interruption.

MATERIALS AND METHODS

In 17 patients undergoing radical resection of pancreaticobiliary carcinoma with simultaneous hepatic artery excision (n=15) or intraoperative hepatic artery obstruction (n=2), morbidity and mortality were reviewed. Nine hepatic artery anastomoses were performed in 7 of these patients, and postoperative patency was obtained for 5 anastomoses. The patients were classified into the following groups: group I was 6 patients with complete interruption of hepatic arterial flow to the whole liver or the remnant liver, group II was 6 patients with interruption of hepatic arterial flow to a lobe of the liver, and group III was 5 patients with preservation of hepatic arterial flow.

RESULTS

Disruption of the bilioenteric anastomosis occurred in all 6 patients from group I versus none of those in groups II and III (p<0.05). Liver abscess and liver failure developed in 1 patient each from group I, but the mortality rate in this group was not high.

CONCLUSIONS

Hepatic artery reconstruction in patients with complete interruption of hepatic arterial blood flow appears to be necessary to avoid ischemic breakdown of the bilioenteric anastomosis.

Corticosteroid weaning late after heart transplantation: relation to HLA-DR mismatching and long-term metabolic benefits

BACKGROUND

To avoid the long-term side effects of corticosteroids, corticosteroid-free immunosuppression has been introduced immediately or late (more than 6 months) after heart transplantation. Late corticosteroid weaning may have a higher success rate as patients are selected on the basis of rejection history. Previous reports of HLA-DR mismatching and the long-term metabolic benefits with respect to corticosteroid weaning have been equivocal.

METHODS

One hundred and one eligible heart transplant recipients receiving triple-drug immunosuppression 6 months from heart transplantation were weaned from prednisone by decreasing the daily prednisone dose by 1 mg each month. Moderate rejection episodes were recorded and after conclusion of the study, HLA-DR mismatching of recipient and donor was reviewed. Serum cholesterol level, body weight, and number of patients receiving blood pressure medications were recorded before and 1 year after corticosteroid weaning.

RESULTS

Successful weaning from corticosteroids was achieved in 82% of patients. Of 31 patients with zero or one HLA-DR mismatch, 30 (97%) were successfully weaned. For those patients more than 1 year after discontinuation of corticosteroids, 67 had more weight loss and a lower serum cholesterol level than 15 patients who were unsuccessful at corticosteroid weaning and dependent on corticosteroids.

CONCLUSIONS

Heart transplant recipients can safely be weaned from corticosteroids late after heart transplantation with zero or one HLA-DR mismatch conferring a higher success rate. The long-term metabolic benefits of corticosteroid weaning include a reduction in weight and serum cholesterol.

The University of California at Los Angeles experience in heart transplantation

In the last decade, the number of patients undergoing heart transplantation has steadily increased as a result of expanding indications for cardiac transplantation. The limitation on the number of transplants performed has been the number of donor organs available. At UCLA, 511 heart transplant procedures were performed from 1984-1994. The mean number of rejection episodes and infections per patient in the first year after transplant was 1.1+/-1.3 and 1.0+/-1.2, respectively. Actuarial one-, 3-, and 5-year survival rates were 84%, 77% and 73%, respectively. Survival of patients age 60 years and over (n=105) was comparable to that of patients under age 60. Despite transplanting more critically ill patients (Status 1) and having longer cold ischemic times, outcomes have been improving. We have been pursuing corticosteroid-free immunosuppression, which no doubt has led to the decrease in infection complications. Furthermore, our work with pravastatin early after transplantation has led to a decrease in clinically severe rejection episodes which has translated into improved survival. Pravastatin also appeared to decrease the development of transplant coronary artery disease and appeared to have an adjunct immunosuppressive effect in our heart transplant patients on CsA-based immunosuppression. Future studies will include the use of mycophenolate mofetil which has properties against B-lymphocytes in addition to T-lymphocytes to block both humoral and cellular rejection. Our program continues to seek better ways to improve survival and the quality of life of our patient population.

[A study of effective administration of recombinant interferon-gamma in renal cell carcinoma regarding immunological influence on peripheral blood lymphocytes]

Immunological effect of recombinant interferon gamma (IFN-gamma) was studied in 18 cases of renal cell carcinoma. Sixteen of them were administered IFN-gamma as post-operative adjuvant therapy. Two of them were administered IFN-gamma for metastatic renal cell carcinoma. All of them were followed for at least 1 year. We divided the patients into two groups. One group subcutaneously received IFN-gamma every other day for 16 days, then 4 weeks later every week for one year (group A), and the other group, received alternate subcutaneous IFN-gamma every other day for 16 days and every week for 4 weeks (group B). For immunological testing, peripheral blood lymphocytes were obtained before treatment on day 1, 2 weeks later, 6 months later and 12 months later. The cells were tested for natural killer activity (NK), antibody dependent cellular cytotoxicity (ADCC), positive lymphocytes of CD3, CD4, CD8 and CD11b. Both ADCC and NK activity were increased after therapy, especially in group B. CD3, CD4 and CD8 positive lymphocytes were increased by means of IFN-gamma. On the other hand, CD11b-positive lymphocytes could not be elicited in group B. Tumor regression was observed in 2 cases of metastatic renal cell carcinomas. When clinical responses were observed, both ADCC and NK were elicited as compared with the pretreatment values. Our findings indicated that ADCC and NK could be elicited in group B.

[Clinical trial of inhalant recombinant interferon-gamma in patients with pulmonary metastasis from renal tumor (preliminary report)]

Recently, we applied inhalation of recombinant interferon (IFN)-gamma, to 4 patients with pulmonary metastatic tumor (3 with renal cell carcinoma and 1 with renal pelvic tumor). Of the patients with renal cell carcinoma 2 had received previous nephrectomy, 1 patient had received embolization alone, 1 subcutaneous IFN-gamma in 1, and 1 systematic chemotherapy. All 4 patients inhaled 1 x 10(6) JR U-2 x 10(6) JR U recombinant IFN-gamma 3 times per day. Additionally, all metastatic renal cell carcinomas received subcutaneous injection of IFN-gamma. One patient with renal cell carcinoma achieved a complete response after inhalation therapy and 2 patients did not respond (NC: 1, PD: 1). A case of metastatic renal pelvic tumor did not respond. Immunohistochemical staining with antibody to Ber-MAC3 (stimulated macrophage) of this case revealed positive cells within the transitional cell carcinoma. According to these results, inhalation of IFN-gamma appears to be applicable as one treatment for pulmonary metastatic tumor of renal cell carcinoma.

Right portal embolization before extended right hepatectomy using laparoscopic catheterization of the ileocolic vein: a prospective study

Preoperative embolization of the right portal vein branch before extended right hepatectomy for hepatocellular carcinoma or hilar cholangiocarcinoma has been recommended for the prevention of postoperative liver failure. Percutaneous transhepatic insertion into the intrahepatic portal vein and insertion into the ileocolic vein at open laparotomy are used for inserting a catheter introducer into the portal vein. We devised a new technique for the laparoscopic insertion of a catheter introducer into the ileocolic vein and used it for right portal embolization in three patients. Measurement of hepatic volume by computed tomography 3 weeks after right portal embolization showed a 28.6 to 66.0% increase in the volume of the predicted remnant liver. This minimally invasive procedure has three advantages: reduction of postoperative pain, avoidance of hepatic injury, and the opportunity for a laparoscopic observation of the liver and the intra-abdominal organs before right portal embolization and hepatectomy.

New flow cytometric method for surface phenotyping basophils from peripheral blood

To clarify the role of basophils in the pathogenesis of allergic disease, we developed a new method for performing surface phenotyping of these cells in centrifugation-enriched mononuclear cell fraction. This method identified basophils on the basic of a negative reactivity with mixed FITC-conjugated monoclonal anti-bodies (mAbs) (anti-CD2, -CD14, -CD16, and -CD19) with analysis performed by flow cytometry. The validity of this approach was confirmed by sorting experiments. Various PE-conjugated mAbs were also used to examine binding to FITC-negative basophils. Basophils from asthmatic patients (n = 14) as well as from normal subjects (n = 6) were shown to express CDw32 (Fc gamma RII), CD25 (IL-2R), but not CD64 (Fc gamma RI). We also detected binding of IgG1 and IgG4 to basophils. This method of phenotyping was very rapid and simple. It thus appears to be useful in the study of allergic disease, as well as of the biology of the basophil.

[Immunological effect of recombinant interferon-gamma in renal cell carcinoma]

The immunological effect of interferon-gamma (IFN-gamma) was investigated in 18 cases of renal cell carcinoma before and after the operation. In 6 patients, IFN-gamma was administered preoperatively for 21 days (administration group), while 12 patients underwent nephrectomy alone without preoperative treatment (control group). The peripheral immunological effects were measured at before and 12 days after the operation in the administration group and at 11 days in the control group. In the administration group, a marked increase was noted in the test of antibody dependent cell-mediated cytotoxicity (ADCC) activity and natural killer (NK) activity, and slight increase in CD4/8 and CD11b. In low stage cases, no appreciable effect was obtained by the administration of IFN-gamma. However, in high stage cases, IFN-gamma tended to increase the value of ADCC activity and NK activity. Immunohistochemical studies of tumor infiltrating lymphocytes in renal cell carcinoma showed a high incidence of CD8 and CD11b in the administration group. Moreover, the presence of CD8 was higher than that of CD4 in the administration group in contrast to the results of the peripheral blood analysis.

Is intravenous glucocorticoid therapy better than an oral regimen for asymptomatic cardiac rejection? A randomized trial

OBJECTIVES

This study assessed whether treatment with oral prednisone (bolus plus tapered doses) is comparable to intravenous methylprednisolone sodium succinate (Solu-Medrol) therapy in patients with asymptomatic moderate cardiac allograft rejection episodes without hemodynamic compromise.

BACKGROUND

Intravenous Solu-Medrol therapy is frequently administered for moderate rejection episodes after heart transplantation but has not previously been compared with an oral prednisone therapy for asymptomatic cardiac rejection in a randomized trial. Compared with oral prednisone therapy, the administration of intravenous Solu-Medrol is more costly and resource intensive, and it can require loss of work time for patients and the family members who accompany them to treatment.

METHODS

Forty-one heart transplant patients with 43 episodes of asymptomatic moderate cardiac rejection were randomized to receive 3 days of 1,000 mg of intravenous Solu-Medrol (20 episodes) or prednisone as a bolus dose of 100 mg orally for 3 days, tapering to the previous maintenance dosage over 14 days (23 episodes). Follow-up endomyocardial biopsies were performed at 2 and 4 weeks. Infectious complications were monitored and the cost of the two forms of therapy was assessed.

RESULTS

Resolution of moderate rejection occurred within 4 weeks in 19 (95%) of 20 patients treated with intravenous steroids and in 21 (91%) of 23 patients treated with oral prednisone. No significant difference in infectious complications occurred between the two groups in the ensuing 3 months after therapy. The cost of the oral prednisone therapy was $6.30 compared with the cost of $180 to $966 for administration of intravenous Solu-Medrol.

CONCLUSIONS

Oral prednisone (bolus plus tapered doses) appears to be as effective and to have similar infectious complication rates as intravenous Solu-Medrol for the treatment of asymptomatic cardiac rejection. The convenience and lower cost of oral prednisone therapy may warrant its routine use for this type of cardiac rejection.

Does short-course induction with OKT3 improve outcome after heart transplantation? A randomized trial

OKT3 is often used routinely for induction immunotherapy or selectively to avoid acute cyclosporine nephrotoxicity in heart transplant recipients at high risk for immediate postoperative kidney failure. It has not been shown in a randomized trial to be useful in patients at low risk for early kidney failure. We randomized 30 patients with a serum creatinine level of less than 1.4 mg/dl before heart transplantation to be treated with triple-drug immunotherapy with cyclosporine, which was started before surgery, (group 1) or to be treated with OKT3 for 4 to 6 days after surgery with oral cyclosporine, which was started between days 2 and 4, after renal function had stabilized (group 2). Follow-up for 6 months revealed no significant differences in the total number of rejection episodes, total number of infections, or in the serum creatinine level. Four patients in group 1 and five patients in group 2 have had no rejection. OKT3 showed a trend to delay time to first rejection (p = 0.10), as has been reported for the 14-day induction course of OKT3. A short course of OKT3 induction in heart transplant recipients at low risk for immediate postoperative kidney failure prolongs the time to first rejection for most patients but does not appear to reduce the total incidence of rejection in the first 6 months after heart transplantation.

Purification of human blood basophils using negative selection by flow cytometry

Basophils were purified from peripheral blood of normal donors using Percoll discontinuous gradients and negative selection by flow cytometry. The mean purity of basophils obtained was 84.7 +/- 4.1 (s.d.)% (range 77.3-90.0%, n = 13). The overall yield of these procedures was 16.0 +/- 2.6% (range 11.0-19.9%, n = 13), and cell viability of purified basophils exceeded 90%. Properties of highly purified basophils obtained by flow cytometry did not differ from those of partially enriched basophil preparations from Percoll discontinuous gradients in respect of: (i) intracellular histamine content; (ii) percentage of spontaneous histamine release in buffer; and (iii) percentage of histamine release triggered by ionophore A 23187 or anti-IgE. Moreover, purified basophils responded chemotactically to complement C5a in a dose-dependent manner. These findings suggest that our procedure for purification of human basophils does not affect the functions of basophils and may be useful for in vitro studies on the role of basophils in hypersensitivity reactions such as bronchial asthma.

Initial success of steroid weaning late after heart transplantation

Steroid-free maintenance immunosuppression is frequently initiated early after transplantation. There is concern that later steroid withdrawal, particularly after previous rejection, may cause more serious rejection. To determine the safety of gradual weaning from steroid maintenance, 68 patients (more than 6 months from transplantation) were weaned from 5 mg/day by decreasing the daily dose by 1 mg each month, with monthly biopsies. Asymptomatic moderate rejection occurred in 13 compliant patients. Rejection with hemodynamic compromise occurred in two patients with documented medication noncompliance, who were excluded from further analysis. Successful weaning without rejection was possible in 53 of 66 (80%) compliant patients. Compared with the rejection group, there were no differences in the number of women, previous rejection episodes, or time from transplantation. All moderate rejection episodes responded to oral steroid pulse therapy. The two serious rejections after noncompliance responded to OKT3. There were no symptoms from steroid withdrawal that required taper alteration. We conclude that regardless of previous rejection episodes, weaning from maintenance steroids can be attempted safely if guided by frequent biopsy procedures, but compliance is critical.

Low-dose lovastatin safely lowers cholesterol after cardiac transplantation

Hypercholesterolemia occurs in many cardiac transplant patients and may aggravate graft coronary arteriopathy as well as contributing to peripheral vascular disease. Lovastatin, which inhibits 3-hydroxy-3-methylglutaryl coenzyme A reductase, in doses of 40-80 mg/day effectively lowers cholesterol in the general cardiac population but has been associated with rhabdomyolysis in cardiac transplant recipients. To determine whether lower doses of lovastatin would be effective and safe for lowering cholesterol after cardiac transplantation, 44 patients with blood cholesterol greater than 200 mg/dl at least 6 months after cardiac transplantation received 10-20 mg lovastatin daily. In addition, lovastatin enzyme inhibitor level was assayed in six patients to determine whether metabolism of the drug was abnormal. Lovastatin decreased total cholesterol by 28% from 282 +/- 54 to 208 +/- 62 mg/dl (p less than 0.005), primarily because of reduction in the low-density lipoprotein fractions, and was well-tolerated without any symptoms or abnormal creatine phosphokinase levels in 43 of 44 patients. One patient developed rhabdomyolysis and reversible renal failure when lovastatin was increased to 40 mg daily. Enzyme inhibitor levels in the six transplant patients were 4.2-7.8 times higher than those measured in normal volunteers. Low-dose lovastatin effectively lowers cholesterol in patients after transplantation, but metabolism is altered, perhaps by cyclosporine. Monitoring of enzyme inhibitor levels may be required to allow safe administration of this drug to cardiac transplant recipients.