Corneal Epithelial Deficiency Induced by the Use of β-Blocker Eye Drops

Two studies were conducted to check the effects of β-blocker eye drops, 2% carteolol (Mikelan®) and 0.5% timolol (Timoptol®), on regeneration of corneal epithelium in rabbit eyes. For the short-term study, epithelial deficiency was artificially induced in the cornea of albino rabbits. One of the β-blocker eye drops or 0.005% benzalkonium chloride was applied in the right eye and physiological saline solution was applied to the left eye four times a day, and wound healing rate was calculated. Two weeks later, images of the surface epithelium were analyzed by scanning electron microscopy and proliferative capacity was studied, using proliferating cell nuclear antigen as a marker. The long-term study was conducted similarly except that the eye drops were applied twice a day and epithelial deficiency was re-induced every two weeks.

In the short-term study, epithelial wound healing rate was slowed in β-blocker groups. Significant differences were detected between the Mikelan® and Timoptol® groups, and the benzalkonium and physiological saline groups. The β-blocker groups had severe epithelial cell desquamation, as well as detachment. In the long-term study, the Mikelan® group had significantly delayed wound healing at first induction, the benzalkonium group showed delay up to the third induction and the Timoptol® group up to the fifth induction. These studies indicate that β-blocker eye drops delay corneal epithelial wound healing and supported the concept that corneal epithelial deficiency occurs clinically after the long-term administration of β-blocker eye drops.

Prevention of steroid-induced osteonecrosis of femoral head in systemic lupus erythematosus by anti-coagulant

Although osteonecrosis of femoral head (ONF) is one of the serious complications in systemic lupus erythematosus (SLE) associated with corticosteroid therapy, there has been few trials of prevention of ONF described. We aimed to prevent ONF in steroid-treated SLE patients using anticoagulant, warfarin, conducting a multicenter prospective study. Sixty newly diagnosed SLE patients requiring 40 mg/day or more prednisolone were alternately assigned to either of two groups; a warfarin group and a control one. Warfarin (1 ∼ 5 mg/day) was started together with the beginning of steroid therapy and continued at least for three months. Patients were observed for the development of silent ONF by magnetic resonance imaging (MRI) and symptomatic ONF by plain radiography for over five years. The warfarin group consisted of 31 patients (62 hips) and the control one 29 patients (58 hips). Silent ONF developed in 13 hips (21%) and 19 hips (33%) in the warfarin group and the control group, respectively ( P = 0.13). On the other hand, warfarin tended to prevent symptomatic ONF; only three hips of 62 (4.8%) in the warfarin group and eight hips of 58 (14%) in the control group ( P = 0.08) developed silent ONF. It was also found that silent ONF developed, if it did, very early; within three months in 16 of 18 patients (89%). Among risk factors for silent ONF, steroid pulse therapy was most outstanding and it seemed to overcome the effect of warfarin. Taken together, for the time being, anticoagulant therapy, if not significantly sufficient, may be of use for the prevention of steroid-induced ONF in SLE. We consider that this study added to important evidence for the pathogenesis and prevention of ONF.

Autoantibody-producing RP105(-) B cells, from patients with systemic lupus erythematosus, showed more preferential expression of BCMA compared with BAFF-R than normal subjects

OBJECTIVE

B cells lacking RP105 produce autoantibodies in patients with SLE. Expression of B-cell activating factor (BAFF) binding receptors (BBRs) and survival of RP105(-) B cells from SLE patients were examined.

METHODS

Detection of difference of gene expression between RP105(-) and RP105(+) B cells was done by DNA microarrays. Surface expression was confirmed by flow cytometry. The contribution of BAFF, a proliferation-inducing ligand (APRIL) and monomers/trimers of sCD40L to survival of RP105(-) and RP105(+) B cells was examined.

RESULTS

Gene expression of B-cell maturation antigen (BCMA) was different among BBRs in RP105(-) and RP105(+) B cells in SLE. Preferential expression of BCMA on RP105(-) B cells was confirmed compared with RP105(+) B cells by flow cytometry, although BAFF receptor (BAFF-R) expression on RP105(-) B cells was significantly lower. Additionally, relative ratios of BCMA/BAFF-R expression on RP105(-) B cells were increased significantly in SLE patients compared with normal subjects. Stimulation by sCD40L decreased the number of surviving RP105(-) and RP105(+) B cells in vitro. RP105(+) B cells were not rescued from sCD40L-induced cell death by BAFF and/or APRIL. In contrast, either BAFF or APRIL maintained the survival of RP105(-) B cells due to avoidance of cell death. Activated RP105(-) B cells reduced BAFF-R and increased BCMA levels.

CONCLUSIONS

RP105(-) B cells from SLE patients showed more preferential expression of BCMA compared with BAFF-R than normal subjects, and were possibly regulated by BAFF/APRIL. Our results provide a new insight of BCMA and their ligands in B cells from SLE patients.

High expression of Toll-like receptor 4 on CD14+ monocytes in acute infectious diseases

Toll-like receptor 4 (TLR4) recognizes lipopolysaccharide (LPS) and other exogenous and endogenous molecules, and is thought to contribute to defense mechanisms against infections. Our objective was to elucidate the clinical significance of TLR4 in acute infectious diseases by analyzing its sequential expression on CD14+ monocytes. Peripheral blood samples were obtained from 36 patients with acute infectious diseases on admission and after treatment within certain intervals. The TLR4 expression on CD14+ monocytes was analyzed using flow cytometry and was presented as a mean fluorescence intensity (MFI). TLR4 expression during the acute phase of infection was highly enhanced compared to that of normal subjects (MFI: 22.1 vs 8.5). TLR4 expression was promptly reduced to normal levels in parallel with the disease improvement. In patients who died despite treatment, the enhancement of TLR4 expression during the acute phase was less prominent compared to those who survived (MFI: 14.6 vs 23.5) and its sequential change was also subtle. These results indicate that monocytes respond to acute infections by the induction of TLR4 expression and that a poor response may be associated with a poor prognosis.

Effect of disease activity and corticosteroids on serum levels of soluble endothelial cell protein C receptor in patients with systemic lupus erythematosus

To assess the effects of disease activity of systemic lupus erythematosus (SLE) and high-dose corticosteroids on endothelial injuries, the significance of soluble endothelial cell protein C receptor (sEPCR) and soluble thrombomodulin (sTM) was analyzed. Serum levels of sEPCR and sTM were measured by enzyme-linked immunosorbent assay (ELISA) cross-sectionally in 97 SLE patients, 49 patients with other rheumatic diseases and 22 normal subjects. The changes in these levels upon corticosteroid treatment were also analyzed in 41 patients. The levels of sEPCR and sTM were both higher in SLE and other rheumatic disease patients than in normal subjects. When low-dose corticosteroids were used, both the level of sEPCR and the ratio of positive tests for sEPCR were significantly higher in active SLE patients than in inactive patients [median 2.30 ng/ml (range 0.00-147.10 ng/ml) vs 0.00 ng/ml (0.00-58.90 ng/ml) and 53.5 vs 13.0%, respectively] (P < 0.005). Moreover, the ratio of positive tests for sEPCR was higher after corticosteroid treatment in 9 of 19 (47.3%) SLE patients compared to other rheumatic diseases (3/22; 13.6%). Although the mean level of sTM was significantly higher in active SLE patients than in inactive patients, the ratio of positive tests for sTM was not affected by disease activity or corticosteroids. In conclusion, the positive test for sEPCR is a more sensitive biomarker than that for sTM in reflecting endothelial injuries caused by active disease and often by corticosteroids in SLE.

Micro-Magnetocardiography System With a Single-Chip SQUID Magnetometer Array for QT Analysis and Diagnosis of Myocardial Injury in Small Animals

Development of drugs requires electrophysiological studies of small animals like mice, rats or guinea pigs. Electrocardiography (ECG) of hirsute animals is time-consuming. We have developed a micro magnetometer array with a 9-channel superconducting quantum interference device (SQUID) with a 2.5-mm diameter pickup-coil for noncontacting measurement of magnetocardiograms (MCGs) in small animals. The micro-MCG successfully recorded the PQRST complex in mice, rats and guinea pigs. A regional myocardial injury was made in rat hearts with a cryoinjury probe, and the characteristic pattern of the injury was recorded in the MCG. An anterior myocardial injury created a QS pattern in the MCG, and a posterior myocardial injury created a QR pattern in the MCG. Quinidine-induced QT prolongation was successfully detected by micro-MCG in mice and rats. Simultaneous recording of ECG and MCG was conducted after intraperitoneal administration of quinidine (60 mg/kg) in guinea pigs. QT interval corrected for heart rate (QTc) in both ECG and MCG correlated well. The newly developed micro-MCG may facilitate electrophysiological studies of small animals, and may enable high-throughput screening of drug-induced QT abnormality.

IL-12p40 is essential for the down-regulation of airway hyperresponsiveness in a mouse model of bronchial asthma with prolonged antigen exposure

BACKGROUND

We previously reported a mouse model of bronchial asthma showing eosinophilic inflammation, but not airway hyperresponsiveness (AHR), after prolonged antigen exposure. This model showed an increase of IL-12 in the lung.

OBJECTIVE

The aim of this study was to investigate the role of IL-12p40 in a murine asthma model with prolonged antigen exposures.

METHODS

An ovalbumin (OVA)-induced asthma model was first established in wild-type (WT) and IL-12p40-deficient (IL-12p40(-/-)) mice. Both strains of mice were further exposed to either OVA (prolonged exposure group) or phosphate-buffered saline (positive control group) 3 days per week for 3 weeks. During week 4, both groups of mice were given a final challenge with OVA.

RESULTS

Prolonged antigen exposures resulted in marked suppression of airway eosinophilia in both WT and IL-12p40(-/-) mice. However, AHR persisted in IL-12p40(-/-) but not in WT mice. There were no significant differences of IL-5, IL-13 or IFN-gamma levels in bronchoalveolar lavage fluid between WT and IL-12p40(-/-) mice. The hydroxyproline content of the lung and peribronchial fibrosis were, however, significantly increased in IL-12p40(-/-) mice.

CONCLUSION

The results suggest that endogenous IL-12p40 is essential for inhibition of AHR and peribronchial fibrosis, but not eosinophilic inflammation, in a murine asthma model with prolonged antigen exposures.

Circulating KL-6/MUC1 as an independent predictor for disseminated intravascular coagulation in acute respiratory distress syndrome

OBJECTIVES

Acute respiratory distress syndrome (ARDS) patients show high levels of circulating mucin including KL-6/MUC1 (soluble MUC1 mucin). Because cancer mucin can bind vascular endothelial cells and platelets via selectins, mucin-selectin interactions are reported to trigger platelet aggregation and intravascular coagulation. Therefore, we hypothesized that KL-6/MUC1 is involved in the pathogenesis of disseminated intravascular coagulation (DIC) in ARDS. The aim of the current study is to evaluate the association between circulating KL-6/MUC1 and DIC in ARDS patients.

DESIGN

Observational study with structured follow-up.

SETTING

Intensive care unit in Hiroshima University Hospital.

SUBJECTS

Fifty-six newly diagnosed patients with ARDS.

INTERVENTIONS

Circulating levels of KL-6/MUC1 were measured during diagnosis and serially measured during the clinical course along with indices of respiratory failure, inflammation, coagulation and fibrinolysis and multiple organ dysfunction.

RESULTS

Acute respiratory distress syndrome patients complicated with DIC showed significantly higher levels of serum KL-6/MUC1 than patients without DIC during the clinical course. Amongst the parameters analysed at diagnosis of ARDS, KL-6/MUC1 was an independent predictor for DIC complication. The baseline level of circulating KL-6/MUC1 at diagnosis of ARDS was significantly correlated with an increased DIC score following ARDS diagnosis. Using an optimum cutoff level of KL-6/MUC1 obtained by a receiver operating characteristic curve, the sensitivity and specificity for predicting future DIC development in ARDS patients were 88.9% and 55.3%, respectively.

CONCLUSIONS

These results suggest that KL-6/MUC1 is associated with DIC development in ARDS patients. Elevated levels of KL-6/MUC1 at diagnosis could be a predictor of DIC complication in ARDS.

Increase of RP105-lacking activated B cells in the peripheral blood and salivary glands in patients with Sjögren's syndrome

OBJECTIVE

To quantify the activated B cells in the peripheral blood and salivary glands of patients with Sjögren's syndrome (SS) by analyzing the expression of RP105 molecule on the B cells.

METHODS

The expression of RP105 on the peripheral blood B cells of patients with SS (19 cases) was analyzed by flow cytometry. RP105-positive and negative B cells were sorted and cultured in vitro and the amount of immunoglobulins (IgG and IgM) produced in the supernatant was measured by enzyme-linked immunosorbent assay (ELISA). Salivary gland biopsy samples from 9 SS patients were histologically evaluated and the sequential frozen sections were separately immunostained by anti-RP105 and anti-CD20 monoclonal antibodies.

RESULTS

A significantly higher proportion of peripheral blood RP105-negative B cells was found in SS patients than in healthy individuals. RP105-negative, but not positive, B cells from SS patients were capable of producing IgG and IgM spontaneously in vitro, which was enhanced by the addition of Staphylococcus aureus Cowan I strain (SAC) or IL-6. Salivary glands from 2 of 9 SS patients were found to have lymphoid follicles whose germinal centers consisted of RP105-negative B cells. Moreover, a larger proportion of B cells extensively infiltrating the area other than lymphoid follicles was also RP105-negative.

CONCLUSION

RP105-negative B cells, a subset of highly activated and well differentiated B cells, which are increased in number in the peripheral blood and extensively infiltrate salivary glands, may be responsible for the production of class-switched immunoglobulin in SS. In addition, those cells might be associated with the inflammation and tissue damage of the salivary glands.

A Case of Visceral Larva Migrans Due toToxocara canisShowing Varied Manifestations

A 21-year-old woman admitted for a low-grade fever, dry cough, polyarthralgia, and general fatigue was found to have elevateal accustomed to eating raw meat and cattle liver peripheral blood eosinophil counts and serum IgE. Chest X-ray imaging and computed tomography (CT) showed multiple small nodules in both lung fields. A multiple dot-ELISA assay of her serum showed that she had visceral larva migrans caused by Ascaris suum or Toxocara canis. Following treatment with albendazole, she developed myelopathy and was again admitted. A cerebrospinal fluid examination showed increased eosionophils and significant antibody elevation against T. canis. Her disease was considered to have entered the central nervous system, one of the target organs of visceral larva migrans. She was successfully treated with dietylcarbamazine and has shown no reccurrence. This case showed the different manifestations of visceral larva migrans and the rising incidence of this disease in Japan raises concerns about associated of diet.

Antifibrotic effects of hepatocyte growth factor on scleroderma fibroblasts and analysis of its mechanism

We investigated the effect of hepatocyte growth factor (HGF) on collagen metabolism in cultured fibroblasts from scleroderma (SSc) patients and discussed the possible mechanism of its effect. Synthesis of matrix metalloproteinase-1 (MMP-1) and collagen and mRNA levels of various cytokines were examined by enzyme-linked immunosorbent assay and real-time polymerase chain reaction, respectively. Hepatocyte growth factor enhanced MMP-1 production and mRNA levels of MMP-1 and Ets-1 (a transcriptional factor of MMPs). In addition, HGF suppressed collagen synthesis and mRNA levels of procollagenalpha1(I) and connective tissue growth factor (CTGF) in SSc fibroblasts. Expression of transforming growth factor (TGF)-beta1 was not inhibited significantly in SSc or control fibroblasts. Hepatocyte growth factor also increased interferon (IFN)-gamma mRNA significantly in SSc and control fibroblasts. Addition of anti-HGF antibody neutralized these effects of HGF on MMP-1 and collagen synthesis. The results suggest that HGF can suppress collagen accumulation in SSc fibroblasts by increasing MMP-1 levels possibly via activation of Ets-1 and also by decreasing collagen synthesis, which may be partly related to inhibition of CTGF, and increasing IFN-gamma levels rather than the effect on TGF-beta1. The present study indicates that HGF may be a promising therapeutic agent for this intractable disease.

The association of Behçet's disease with myelodysplastic syndrome in Japan: a review of the literature

OBJECTIVE

[corrected] To determine the clinical characteristics of patients with myelodysplastic syndrome (MDS)-associated Behçet's disease (BD) in Japan.

METHODS

54 Japanese cases of MDS-associated BD obtained from the literature and from our own clinical experience were reviewed. The clinical features of MDS-associated BD were compared with those of the 1991 nationwide BD survey in Japan.

RESULTS

In MDS-associated BD, the average age at onset was 42.6 years, which was 6.9 years later than for all BD patients; females developed disease more frequently than males (male: female ratio = 0.80). In MDS-associated BD cases, the occurrence of eye lesions was significantly lower, the frequency of intestinal lesions was markedly higher, and the rate of HLA-B51 positivity was lower than that in all BD. BD and MDS developed nearly simultaneously in 49.0% of cases; BD preceded MDS in 31.4% of the cases. The distribution of the age at BD onset showed two peaks, one in the 3rd decade and the other in the 6th decade. Females were more likely to develop younger-onset disease, while men were more likely to develop older-onset MDS-associated BD. Furthermore, in the older-onset group, BD was diagnosed together with or after the diagnosis of MDS, while half of the younger-onset group developed BD earlier than MDS.

CONCLUSION

MDS-associated BD patients form a distinct subset of patients. There may, in fact, be two major groups of MDS-associated BD patients based on age, gender, and temporal relationship of the two diseases.

Role of inducible costimulator in the development of lupus in MRL/lpr mice

Inducible costimulator (ICOS) is a costimulatory molecule expressed in activated T cells and plays an important role in T-cell-dependent immune responses. We investigated the role of ICOS in the development of autoimmune diseases in MRL/Mpj-lpr/lpr (MRL/lpr) mice. ICOS was expressed on CD4(+) T cells from adult MRL/lpr mice. ICOS-deficient MRL/lpr mice showed mild lymphoadenopathy and a decreased memory type CD4(+) T cells in the spleen. The anti-dsDNA antibody levels were decreased. CD4(+) T cells from ICOS-deficient MRL/lpr mice showed less of a bias to Th1 and an enhanced production of IL-4 in response to anti-CD3 antibody in comparison to those from wild-type MRL/lpr mice. Although ICOS-deficiency abrogated renal vasculitis completely, the severity of glomerulonephritis was not altered. ICOS is considered to play a role in CD4(+) T cell activation, autoantibody production, and renal vasculitis. However, it is not essentially required in the development of glomerulonephritis.

Ex vivo CD(+) T-cell cytokine expression from patients with Sjögren's syndrome following in vitro stimulation to induce proliferation

OBJECTIVE

To assess ex vivo CD4(+) T-cell cytokine expression from patients with primary Sjögren's syndrome (SS) following in vitro stimulation to induce proliferation, as proliferation is closely related to differentiation of cytokine-producing cells.

METHODS

Peripheral blood mononuclear cells (PBMCs) separated from primary SS patients (n = 28) and controls (n = 25) were analysed. PBMCs were stimulated with concanavalin A followed by phorbol 12-myristate 13-acetate and ionomycin. Intracellular interferon-gamma (IFN-gamma) and interleukin-4 (IL)-4 in proliferating CD4(+) T cells were assessed by flow cytometry. The proportion of cytokine-producing cells and proliferating cells in each division cycle was assessed using [5(and 6)-carboxyfluorescein diacetate, succinimidyl ester]-labelled CD4(+/-) T cells.

RESULTS

The proportion of IFN-gamma+ proliferating CD4(+) T cells in each cell division cycle from extraglandular SS was increased in glandular SS patients compared glandular SS patients with controls (P<0.05 approximately 0.01). The percentage of IFN-gamma single positive proliferating CD4(+) T cells was greater in extraglandular SS patients (26.7+/-14.1%) compared with glandular SS (9.9 +/- 9.1%) (P<0.01) and controls (9.4 +/- 5.8%) (P<0.001). There was no significant difference in the percentages of IL-4(+) proliferating CD4(+) T cells among the groups. However, the proliferating response of CD4(+) T cells was significantly decreased in extraglandular SS patients (percentage of proliferating cells 38.4 +/- 18.6%) compared with that in glandular SS patients (64.2 +/- 17.2%) (P<0.05) and controls (63.1+/-10.6%) (P<0.01).

CONCLUSIONS

CD4(+) T cells from extraglandular SS patients may have a predisposition for entry into the IFN-gamma-producing effector pathway as a result of the stimulations. These results are helpful for understanding the immunological difference between glandular and extraglandular SS and the mechanisms of disease progression.

Two cases of antinuclear antibody negative lupus showing increased proportion of B cells lacking RP105

B cells lacking RP105 molecule, a member of the Toll-like receptor family, were increased in the peripheral blood of 2 patients with antinuclear antibody (ANA) negative systemic lupus erythematosus (SLE). The increased proportion of RP105-lacking B cells was associated with disease activity in patients with ANA-negative SLE. When there are no significant serological markers for SLE, analysis of expression of RP105 may be helpful in evaluation of activity in ANA-negative SLE. We describe a new approach, using phenotyping of B cells, to evaluate activity of ANA-negative SLE.

Increased entry of CD4+ T cells into the Th1 cytokine effector pathway during T-cell division following stimulation in Behcet's disease

OBJECTIVES

To investigate the relationship between the production of Th1/Th2 cytokines and cell kinetics, cell division and proliferation in patients with Behçet's disease (BD).

METHODS

Peripheral venous blood was drawn from patients with BD (n = 24; 10 patients with active and 14 patients with inactive BD) and normal subjects (n = 22). Peripheral blood mononuclear cells were separated immediately and were cultured with concanavalin A (Con A) followed by phorbol 12-myristate 13-acetate and ionomycin (PMA+Ion). Intracellular cytokine production of interferon-gamma (IFN-gamma) (Th1) and IL-4 (Th2) in CD4(+) T cells was determined by flow cytometry. Furthermore, CD4(+) T cells labelled with CFSE [5 (and 6) carboxyfluorescein diacretate, succinimidyl ester] were stimulated and the cells were analysed for entry into the cytokine production effector pathway during cell division in active BD and normal subjects.

RESULTS

In active BD, enhanced entry into the Th1 response effector pathway of CD4(+) T cells was observed after stimulation with Con A followed by PMA+Ion. Analysis of CD4(+) T cells at an identical cell division number in response to Con A followed by PMA+Ion revealed that IFN-gamma-producing cells were increased in active BD patients compared with normal subjects. These results suggest that the Th1 response of dividing CD4(+) T cells is predominantly operating in active BD. Dividing CD4(+) T cells stimulated with Con A followed by PMA+Ion showed a phenotype of activated effector memory T cells (CD45RA(low), CD45RO(+), CD69(high)).

CONCLUSIONS

Cell kinetics play a crucial role in Th1 cell differentiation and pathophysiology in BD.

Acceleration of the onset of collagen-induced arthritis by a deficiency of platelet endothelial cell adhesion molecule 1

OBJECTIVE

Platelet endothelial cell adhesion molecule 1 (PECAM-1; CD31) is a member of the immunoglobulin superfamily that is expressed in platelets, leukocytes, and endothelial cells. PECAM-1 has been shown to play a role in transendothelial migration of leukocytes and contains immunoreceptor tyrosine-based inhibitory motifs in its cytoplasmic tail and inhibits cellular responses. We examined the role of PECAM-1 in the development of collagen-induced arthritis (CIA).

METHODS

CIA was induced in PECAM-1-deficient DBA/1 mice. The incidence of arthritis and the arthritis index were examined. Anti-type II collagen (anti-CII) antibody levels and interferon-gamma (IFNgamma) production by lymph node cells and spleen cells were determined. Lymphocytes from arthritic PECAM-1-deficient and wild-type mice were labeled with dye, transferred to arthritic PECAM-1(+/-) mice, and cell migration to inflamed joints was examined.

RESULTS

PECAM-1-deficient mice showed accelerated onset of arthritis and increased severity only during the early phase. Anti-CII antibody levels were also increased during the early phase. IFNgamma production by lymph node cells and spleen cells from PECAM-1-deficient mice in response to CII was higher than that in wild-type mice. Lymphocytes from arthritic PECAM-1-deficient mice showed accelerated migration to inflamed joints, but not lymph nodes or spleen. The development of anti-CII antibody-induced arthritis was similar in PECAM-1-deficient and wild-type mice.

CONCLUSION

These results indicate that PECAM-1 negatively regulates humoral and cell-mediated immune responses and lymphocyte migration into joints and, consequently, the development of CIA. In addition, the role of PECAM-1 in the transendothelial migration of leukocytes appears to be redundant in this model.

[Efficacy of docetaxel (TXT) combined with cisplatin (CDDP) in non-small cell lung cancer]

A multicenter cooperative study of docetaxel (60 mg/m2) combined with cisplatin (60 mg/m2) was performed in stage III and IV patients with inoperable non-small cell lung cancer from March 1998 to September 1999. Of 37 patients enrolled, 36 patients were eligible. One patient obtained a complete response (CR) and nine patients had a partial response (PR). The overall response rate in 36 patients was 28.6%. The median survival time was 360 days. The response rates of stage III and stage IV patients were 36.8% and 18.7%, respectively. The median survival times of stage III and stage IV patients were 502 days and 286 days, respectively. The major toxicities were grade 3 leukopenia (16.2%), grade 3 neutropenia (32.4%), and grade 4 neutropenia (10.8%).

[Bone marrow accumulation in gallium scintigraphy in patients with adult Still's disease]

We investigated the features and the usefulness of gallium scintigraphy in the diagnosis and the assessment of Adult Still's disease (ASD) by retrospective case review. Gallium scintigraphy have been done for 11 cases of ASD (3 males and 8 females) and 4 females were positive. Among these, 67 Ga-citrate was accumulated to the bone marrow in all 4 cases and to the major joints in 2 cases. Positive cases were rather serious and administered more immunosuppressants than negative cases. In order to characterize gallium scintigraphy findings of ASD, i.e. bone marrow accumulation, we analyzed 130 cases of collagen vascular diseases. Although 101 cases (77.7%) were positive, only 7 cases (5.4%) showed the accumulation of 67Ga-citrate to the bone marrow. These include 3 cases with ASD, and 1 case with systemic lupus erythematosus, polyarteritis nodosa, Wegener's granulomatosis and Sjögren's syndrome. We also accumulated 18 patients who exhibited bone marrow accumulation of 67Ga-citrate, and found that 7 patients had collagen vascular and their related diseases. In conclusion, bone marrow accumulation in gallium scintigraphy is a specific feature of collagen vascular diseases, especially ASD, and it is suggested that cases with positive gallium scintigraphy in ASD can be serious and resistant to treatment.

Angiogenesis and metastasis marker of human tumors

Tumor growth and metastasis are dependent on angiogenesis. Therefore, certain angiogenesis markers may be useful as metastasis markers and/or the targets for antiangiogenic therapy. We and others have been studying endoglin(EDG; CD105) for such purposes. EDG is a proliferation-associated antigen of endothelial cells and essential for angiogenesis. In addition, EDG is a component of the transforming growth factor(TGF)-beta receptor complex. Expression of EDG is up-regulated in tumor-associated angiogenic vasculature compared with normal tissue vasculature. Microvessel density detected for EDG expression in breast cancer tissues showed a statistically significant correlation with overall and disease-free survival. In addition, elevated serum EDG was associated with metastasis in patients with colorectal, breast, and other solid tumors. On the other hand, We have been targeting EDG on tumor vasculature to suppress tumor growth and metastasis by systemic(i.v.) administration of anti-EDG monoclonal antibodies(mAbs) and immunoconjugates(IMCs). To thid end, we have been using three animal models, i.e., severe combined immunodeficient(SCID) mouse model of MCF-7 human breast cancer, human skin/SCID mouse chimera model bearing MCF-7 tumor, and syngeneic metastasis model of colon-26 adenocarcinoma cells in BALB/c mice. In addition, antiangiogenic activities of anti-EDG mAbs and IMCs were evaluated in mice using the dorsal air sac assay. The IMCs were prepared by coupling deglycosylated ricin A-chain or 125I to individual anti-EDG mAbs. These anti-EDG IMCs and mAbs showed substantial antitumor efficacy and antimetastatic activities without showing severe toxicity. Recently, we generated a recombinant human/mouse chimeric anti-EDG mAb to facilitate clinical application of the mAb.

Specific somatosensory processing in somatosensory area 3b for human thumb: a neuromagnetic study

OBJECTIVES

We examined the relation between somatosensory N20m primary responses and high-frequency oscillations (HFOs) after thumb and middle finger stimulation.

METHODS

Somatosensory evoked fields (SEFs) from 12 subjects were measured following electric stimulation of the thumb and middle finger. SEFs were recorded with a wide bandpass (3-2000 Hz) and then N20m and HFOs were separated by subsequent 3-300 and 300-900 Hz bandpass filtering.

RESULTS

The N20m peak-to-peak amplitude did not differ significantly between thumb and middle finger SEFs. In contrast, HFOs had a significantly larger number of peaks and were higher in the maximum amplitude and the total amplitude after thumb stimulation than after middle finger stimulation.

CONCLUSIONS

Our present data demonstrate a different relation between N20m and HFOs after thumb and middle finger stimulation. In view of the fact that the human thumb has uniquely evolved functionally and morphologically, the somatosensory information from the thumb will be processed differently for a fine motor control. We speculate that HFOs are generated by inhibitory interneurons in layer 4 in area 3b. Thus, enhanced activity of interneurons reflected by high amplitude HFOs exerts stronger inhibition on downstream pyramidal cells in area 3b for thumb stimulation.

Multiple logistic regression analysis of risk factors for the development of steroid-dependent asthma in the elderly: a comparison with younger asthmatics

BACKGROUND

The percentage of the aged among all patients with bronchial asthma is increasing.

OBJECTIVE

To investigate the risk factors for the development of steroid-dependent asthma in the elderly.

METHODS

A multiple logistic regression analysis involving various clinical factors between steroid-dependent and -independent asthma was carried out for 59 asthmatics aged over 60 years, including 16 patients with steroid-dependent asthma. The calculated risk for each factor was compared with that obtained from 122 younger asthmatics aged 20-59 years.

RESULTS

Among the factors examined (sex, age, period from onset of asthma, type of asthma and family history of asthma, plus history of smoking, atopic dermatitis, allergic rhinitis, chronic sinusitis and nasal polyps), the significant risk factors for the development of steroid dependency in the elderly asthmatics were only family history of bronchial asthma (relative risk 3.6) and smoking history (relative risk 6.9).

CONCLUSIONS

Some risk factors for steroid-dependent asthma in younger individuals were not significant in the elderly. Since the smoking history was most closely associated with the development of steroid dependency in the elderly, even though most of them had quit smoking, it is important for patients with asthma to avoid smoking.

Association of serum endoglin with metastasis in patients with colorectal, breast, and other solid tumors, and suppressive effect of chemotherapy on the serum endoglin

In this report, we present data indicating that the increased serum endoglin (EDG; CD105) quantitated by a double-antibody sandwich assay is associated with metastasis in patients with solid tumors including colorectal and breast carcinomas. In addition, we show that chemotherapy exerts a suppressive effect on the serum EDG. EDG is a proliferation-associated cell membrane antigen of human vascular endothelial cells. Furthermore, EDG is essential for angiogenesis. We generated two anti-EDG monoclonal antibodies (mAbs), termed SN6a and SN6h, defining different epitopes of EDG and developed a double-antibody sandwich assay to quantitate serum EDG in patients with solid tumors. SN6h possesses an exceedingly high antigen-binding avidity (K, 1.38 x 10(11) liters/mol), whereas SN6a possesses an ordinary avidity for a mAb directed to a cell surface antigen (K, 2.85 x 10(8) liters/mol). We measured serum samples from 101 patients with solid tumors (34 colorectal cancers, 16 breast cancers, and 51 other cancers), 8 patients with benign diseases, and 31 healthy volunteers. The serum level of EDG was significantly elevated in the patients with metastatic cancers. The mean serum EDG in the 42 metastasis-negative patients was 34.0 +/- 26.8 ng/ml (median value, 27.9 ng/ml), whereas the value in the 59 metastasis-positive patients was 63.8 +/- 72.5 ng/ml (median value, 37.2 ng/ml). The difference in EDG levels between the two groups was statistically significant (P = 0.012). Of the colorectal cancer patients, the difference in EDG levels between the 19 metastasis-negative patients and the 15 metastasis-positive patients was statistically significant (P = 0.02). In addition, the difference between the normal control (n = 31) and the 15 metastasis-positive colorectal cancer patients was statistically significant (P = 0.04). Of the breast cancer patients, the difference in EDG levels between the 11 metastasis-positive patients and the normal control was statistically significant (P < 0.005). In additional studies, we found that chemotherapy suppressed serum EDG levels in cancer patients. Of the 54 metastasis-positive patients with solid tumors, the mean serum EDG in the 32 chemotherapy-receiving [chemotherapy(+)] patients was 44.7 +/- 41.9 ng/ml (median value, 36.1 ng/ml), whereas the value in the 22 chemotherapy(-) patients was 102.4 +/- 99.5 ng/ml (median value, 64.8 ng/ml). The difference in serum EDG between the two groups is statistically significant (P < 0.005). In the majority of metastasis-positive patients who were not receiving chemotherapy, serum EDG was elevated. The results suggest that serum EDG may be a useful marker for monitoring early signs of metastasis and cancer relapse in a long-term follow-up of solid tumor patients.

Effects of pranlukast, a cysteinyl leukotriene antagonist, on bronchial responsiveness to methacholine in aspirin-intolerant asthmatics treated with corticosteroids

Cysteinyl leukotrienes (cysLTs) are considered to be the most important mediator involved in the pathogenesis of aspirin-intolerant asthma (AIA). However, the role of cysLTs in the baseline condition of the pathophysiology of AIA when not exposed to non-steroidal antiinflammatory drugs (NSAIDs) as well as that in the pathophysiology of aspirin-tolerant asthma remains to be elucidated. Therefore, we evaluated the effect of pranlukast, a potent, selective cysLT receptor antagonist, on bronchial responsiveness to methacholine, a non-specific stimulus, in 7 well-controlled aspirin-intolerant asthmatics receiving oral or inhaled corticosteroid treatment. Pranlukast was orally administered at a dose of 225 mg twice daily to all patients for 4 weeks, and the methacholine challenge test was performed before and after pranlukast treatment. The methacholine provocative concentration producing a 20% fall in forced expiratory volume in 1 second (PC20-FEV1) was calculated as an index of bronchial hyperresponsiveness (BHR). The geometric mean values of PC20-FEV1 significantly (p = 0.028) increased from 0.34 mg/dl to 0.61 mg/dl after pranlukast treatment. No significant differences were observed in the baseline values of forced vital capacity (FVC) or FEV1 before and after pranlukast treatment. These findings suggest that antagonism of endogenous cysLT by pranlukast may be responsible for the improvement of BHR to methacholine.

Determining the appropriate stimulus intensity for studying the dipole moment in somatosensory evoked fields: a preliminary study

OBJECTIVE

To establish a simple method of determining the appropriate stimulus intensity for studying the dipole moment in somatosensory evoked fields.

METHODS

In 17 patients (20 hemispheres), the authors studied the relationship between the dipole moment and stimulus intensity, which was quantified using the threshold of thenar muscle twitch (TMT). The dipole moment was measured at 1.0, 1.5 and 2.0 TMT. Two measurements were obtained at 1.5 TMT to determine the procedure's margin of error.

RESULTS

There was no significant difference between the dipole moments measured at 1.5 and 2.0 TMT.

CONCLUSIONS

Setting the stimulus intensity at 1.5 TMT or more ensures a consistent response.

Pranlukast, a cysteinyl leukotriene antagonist, reduces serum eosinophil cationic protein levels in patients with asthma

Cysteinyl leukotrienes (cysLTs) are considered to be important mediators involved in bronchial asthma and the ensuing eosinophilic inflammation. We evaluated the effects of pranlukast, a potent and selective cysLT receptor antagonist, on the clinical course and serum eosinophil cationic protein (ECP) levels of 10 asthmatic patients. A four-week administration of pranlukast increased the morning peak expiratory flow (PEF) (p = 0.007) and decreased as-needed beta 2-agonist use (p = 0.021). Changes in the morning PEF inversely correlated with those in the serum ECP levels (r = -0.80, p = 0.0057). These results suggest that cysLTs are important mediators involved in eosinophilic inflammation, a major pathophysiologic feature of bronchial asthma in humans.

Antiangiogenic radioimmunotherapy of human solid tumors in SCID mice using (125)I-labeled anti-endoglin monoclonal antibodies

Endoglin (CD105), which is a component of the TGF-beta receptor complex, is highly expressed at the surface of proliferating human endothelial cells such as those of tumor vessels. In the present study, we tested the antitumor efficacy of (125)I-labeled anti-endoglin monoclonal antibodies (MAbs), SN6f and SN6j, against s. c. tumors of MCF-7 human breast cancer cells in SCID mice by i.v. administration. SN6f and SN6j cross-react weakly with mouse endothelial cells, but show no significant reactivity with MCF-7 tumor cells. These MAbs are effectively internalized into the cells after binding to the cell surface antigen of endothelial cells. Four groups of SCID mice (n = 10 or 9 in each group) inoculated s.c. with 8 x 10(6) MCF-7 cells were treated with (125)I-SN6f (10 microCi), (125)I-SN6j (10 microCi), a (125)I-labeled isotype-matched control IgG (10 microCi) or PBS. The systemic therapy was performed in 2 series, i.e., on days 3, 5, 7 and days 58, 60, 62. Both (125)I-SN6f and (125)I-SN6j showed significant growth suppression of the tumors, whereas the (125)I-labeled control IgG did not show any significant antitumor efficacy. No significant toxicity or weight loss was observed in mice treated with either (125)I-SN6f or (125)I-SN6j. After 100 days of observation, autopsies revealed no significant organ damage. Our results show the possible usefulness of antiangiogenic radioimmunotherapy using (125)I-labeled anti-endoglin MAbs.

Activation of telomerase is induced by a natural antigen in allergen-specific memory T lymphocytes in bronchial asthma

The function of the immune system is known to be dependent on the cellular differentiation and clonal expansion of allergen-specific lymphocytes. Telomerase, a ribonucleoprotein enzyme, is believed to be essential for the indefinite proliferation of human cells. To clarify whether telomerase is involved in the pathogenesis of immune diseases as well as of malignancies, we investigated the upregulation of telomerase activity in allergen-specific T lymphocytes. Upregulation of telomerase in allergen-sensitized lymphocytes was induced not only by artificial mitogenic stimulations but also by the natural antigen, house dust mite, which causes allergic diseases. Moreover, the upregulation of telomerase activity in memory T cells activated during allergen-specific immune responses might be associated with the enduring allergen-specific atopic propensity in asthmatics.

Induction of lasting complete regression of preformed distinct solid tumors by targeting the tumor vasculature using two new anti-endoglin monoclonal antibodies

Endoglin (EDG, CD105) is a proliferation-associated antigen on endothelial cells. In this study, two new anti-EDG monoclonal antibodies (mAbs) Y4-2F1 (or termed SN6j) and P3-2G8 (SN6k) were generated and used for treating distinct preformed tumors. These mAbs, both IgG1-kappa antibodies, cross-reacted weakly with mouse endothelial cells but defined epitopes different from the epitope defined by a previously reported anti-EDG mAb K4-2C10 (B. K. Seon et al., Clin. Cancer Res., 3: 1031-1044, 1997). SN6j and SN6k reacted strongly with human endothelial cells and vascular endothelium of malignant human tissues but showed no significant reactivity with tumor cells per se. The deglycosylated ricin A chain (dgRA) conjugates of the two mAbs showed a weak but specific cytotoxic activity against murine endothelial cells in vitro. In the therapeutic studies, severe combined immunodeficient mice were inoculated s.c. with MCF-7 human breast cancer cells and left untreated until palpable tumors of distinct size (4-6 mm in diameter) appeared. Mice with the distinct tumors were treated by i.v. administration of individual anti-EDG conjugates, unconjugated mAbs, or a control conjugate. Long-lasting complete regression of the tumors was induced in the majority of tumor-bearing mice (n = 8 for each conjugate) when 40 microg of the individual conjugates were administered three times via the tail vein. It is remarkable that the tumors remained regressed without further therapy for as long as the mice were followed (i.e., 100 days). Control conjugate did not induce regression of the tumors in any of the treated mice, although weak nonspecific effects were observed in some of the mice (n = 8). The effects of unconjugated mAbs were small with the dose used, i.e., 34 microg three times. The anti-EDG conjugates showed antiangiogenic activity in the dorsal air sac assay in mice. The results suggest good potential of these conjugates for the clinical application.

Activation of platelets in bronchial asthma

STUDY OBJECTIVES

To investigate whether platelets are activated in asthmatics with increased release of preformed mediators and to investigate the influence of oral administration of theophylline on them.

DESIGN

Comparison of the intracellular free calcium concentration ([Ca2+]i) in platelets as an indicator of platelet activation, CD62P expression on platelets, and the chemokine regulated upon activation in normal T cells expressed and presumably secreted (RANTES) level in platelet-rich buffer supernatants between asthmatics and normal subjects.

SETTING

The respiratory outpatient clinics, Hiroshima University, Japan.

PARTICIPANTS

Twenty-five normal volunteers, 19 asthmatics taking no oral drugs associated with asthma treatment (group A), and 18 asthmatics taking oral theophylline (group B).

MEASUREMENTS AND RESULTS

While the resting [Ca2+]is in platelets were similar among the three groups, the [Ca2+]is in group A were significantly higher than those in normal subjects (p<0.05) and group B (p<0.01) after thrombin or 9,11-epithia-11,12-methano-thromboxane A2 (STA2) stimulation in the absence of external Ca2+. The CD62P expression level and RANTES level in group A after STA2 stimulation were significantly higher than those in normal subjects and group B (p<0.05).

CONCLUSIONS

We conclude that agonist-mediated activation of platelets is augmented in asthmatics resulting in enhanced release of chemokine such as RANTES, which could be suppressed by oral administration of theophylline.

Long-lasting complete inhibition of human solid tumors in SCID mice by targeting endothelial cells of tumor vasculature with antihuman endoglin immunotoxin

In the present study, we developed an antitumor immunoconjugate that appears to be promising as a novel curative antitumor agent against a variety of human solid tumors. We generated a new antihuman endoglin (EDG) monoclonal antibody (mAb) K4-2C10 (or termed SN6f) that cross-reacts with mouse endothelial cells. Such cross-reactive anti-EDG mAbs have not been reported previously. This mAb was used to target tumor-associated vasculature in SCID mice inoculated with human tumors. No anti-EDG mAb or its immunoconjugates have previously been successfully used for targeting vasculature in vivo. In this study, MCF-7 human breast cancer cells were inoculated s.c. into SCID mice. K4-2C10 did not react with the MCF-7 cells but showed a weak reactivity with mouse endothelial cells. The mAb reacted with the proliferating endothelial cells more strongly than with the quiescent endothelial cells. The mAb exhibited much stronger reactivity (>10-fold) with human endothelial cells than with mouse endothelial cells and reacted strongly with vascular endothelium of tumor-associated blood vessels in a variety of human malignant tissues. Conjugates of K4-2C10 with ricin A chain (RA) and deglycosylated ricin A chain (dgRA) showed a weak but specific cytotoxic activity against murine endothelial cells in vitro; the 50% inhibitory dose of the RA and dgRA conjugates was 54 nm and 29 nm, respectively. Remarkable antitumor efficacy was observed when a small amount (a total of 60 microgram corresponding to 24% of the LD50 dose) of the dgRA conjugate was administered i.v. into SCID mice that had been inoculated s.c. with MCF-7. Unconjugated mAb K4-2C10 was not significantly effective in the inhibition of the tumor growth. The immunotoxin (IT) completely inhibited growth of the tumor in all of the treated mice (n = 8). Furthermore, similar antitumor efficacy was observed when the IT was administered i.v. into the tumor-inoculated SCID mice that had been pretreated with unconjugated K4-2C10 to block the potentially available weak binding sites of normal tissues. The strong therapeutic effects of the IT were reproduced in another set of therapeutic experiments. No significant side effects were observed in the mice. The differences in the tumor growth between the control group and the IT-treated groups were statistically significant. The IT showed antiangiogenic activity in the dorsal air sac method. The results indicate that K4-2C10 IT effectively treated the tumor-bearing mice by selectively inhibiting the tumor-associated blood vessels and by disrupting tumor-associated angiogenesis. The strong antitumor efficacy of the K4-2C10 IT is remarkable in view of the fact that K4-2C10 and its IT showed only a weak reactivity with mouse endothelial cells, and a relatively small amount of the IT was administered i.v. to treat s.c. tumors. We anticipate that the K4-2C10 IT will show much stronger antitumor efficacy and antiangiogenic activity in patients with solid tumors and other angiogenesis-associated diseases. The present results demonstrate for the first time that an anti-EDG mAb or its immunoconjugate can effectively target tumor-associated vasculature in vivo.

Increased expression of tumor necrosis factor-alpha, interleukin-6, platelet-derived growth factor-B and granulocyte-macrophage colony-stimulating factor mRNA in cells of bronchoalveolar lavage fluids from patients with sarcoidosis

Cytokines released from activated alveolar macrophages and T-lymphocytes affect the accumulation of monocyte-macrophage-lineage cells and therefore play an important role in the formation of sarcoid granuloma. Although it is likely that certain monokines and lymphokines are involved in the development of sarcoid granulomas, the evidence for this is not unequivocal. In an attempt to clear critical cytokines in the development and maintenance of sarcoid granuloma, we have measured the level of seven cytokine mRNA (TNF-alpha, IL-6, IL-8, TGF-beta, PDGF-B, IFN-gamma, and GM-CSF) in cells obtained by BAL from sarcoidosis patients and normal subjects. To detect cytokine mRNA, we employed a reverse transcription-polymerase chain reaction. We report that the levels of TNF-alpha, IL-6, PDGF-B and GM-CSF mRNA were significantly increased in BAL cells from the patients with pulmonary sarcoidosis compared to controls. No significant differences were observed in the mRNA expression of IL-8, TGF-beta and IFN-gamma. A significant correlation of the expression of the mRNA levels of seven cytokines in the same patients with sarcoidosis was observed between IL-8 and TNF-alpha, PDGF-B, and IL-6, IL-8 and IL-6 and TFN-alpha and PDGF-B and IL-8. This finding indicates that at least these four cytokines are involved in the cytokine network at the local alveolar site of chronic granulomatous inflammation. This study adds a report to the literature that supports a role for cytokine, TNF-alpha, IL-6, PDGF and GM-CSF in particular, in the promotion and maintenance of sarcoid granulomatous inflammation.

Reconstruction of two-dimensional current distribution from tangential MCG measurement

We describe a two-dimensional reconstruction method for tangential magnetocardiograms (MCGs). This method is based on two-dimensional Fourier analysis, and we used a new type of window function for tangential MCG to solve the problem of the small number of measurement points. By using this method, cardiac activity can be estimated as a two-dimensional current distribution. To determine the effectiveness of this method, we measured tangential MCGs of normal subjects, and compared the estimated current distribution with the actual cardiac muscle activity. Using this method, we were able to clearly show cardiac activity.

Coronary artery bypass grafting without cardiopulmonary bypass for high-risk patients

Between January 1991 and June 1993, coronary artery bypass grafting was performed without either cardiopulmonary bypass or cardiac arrest in 23 patients. Most patients had several surgical risk factors, including age > or = 70 years, poor left ventricular function, left main coronary artery stenosis, chronic renal failure, and aortic aneurysm. Distal anastomoses were made under temporary interruption of coronary flow. A total of 37 distal anastomoses to the left anterior descending coronary artery and/or right coronary artery (mean 1.6 per patient) were made, 24 of which were internal thoracic arteries. The coronary occlusion time ranged from 7-14 min (mean 9.8 min). Combined cardiac or vascular operations were carried out in six patients (abdominal aortic aneurysm repair, thoracic aortic aneurysm repair, carotid endarterectomy, and coronary endarterectomy). There was one hospital death. Postoperative angiography was performed in 22 patients and showed a patency rate of 89%. In summary, coronary artery bypass grafting without cardiopulmonary bypass may improve the postoperative outcome of high-risk patients.

The treatment of chronic hemodialysis vascular access by directional atherectomy

Directional atherectomy (DA) was developed as a new therapeutic modality for coronary artery disease. For the past 3 years, we have applied DA intervention to vascular access failure with either poor blood flow rate or high venous pressure. DA intervention was performed on 27 lesions of 16 hemodialyzed patients. A reduction of stenosis to less than 20% of that before treatment was judged a technical success, and the rate of technical success was 84%. All patients showed adequate blood flow rates after DA intervention, indicating initial success. Although restenotic events occurred frequently, repeated DA interventions could be performed successfully. The patency rate at 1 month after DA intervention was 100%, at 3 months 93%, at 6 months 92% and at 12 months 75%. The short-term patency rate of DA was more satisfactory than the results of percutaneous transluminal angioplasty as reported by several investigators. Regarding the site of stenosis, restenotic events were relatively fewer in the lesions occurring at the native vein compared to those at graft-venous anastomotic sites. Eccentric-type stenosis was also associated with fewer restenotic events than circumferential-type stenosis. These results suggest that eccentric-type stenosis at the native vein is the most suitable lesion for the application of DA intervention in terms of long-term patency. As no severe complications occurred after DA intervention, this would appear to be a useful therapeutic modality for the correction of vascular access failure.

[Usefulness of open lung biopsy for corrective surgery on incomplete atrioventricular septal defect associated with severe pulmonary hypertension and right to left shunting]

In congenital heart defects, it is sometimes difficult to decide the operative indication in patients, who has severe pulmonary hypertension (PH) and right to left shunting, from clinical symptoms and cardiac catheterization. We here report a case of incomplete atrioventricular septal defect. The patient is 9 months old with the Down's syndrome. The cardiac catheterization showed severe PH and right to left shunting. Preoperative mean pulmonary artery pressure was 75 mmHg, pulmonary systemic pressure to systemic pressure ratio (PP/PS) was 1.17, pulmonary systemic flow to systemic flow ratio (QP/QS) was 0.79, pulmonary systemic resistance to systemic resistance ratio (RP/RS) was 1.54 and pulmonary vascular resistance (PVR) was 9.6 woodunits.m2. These data suggested that the irreversible pulmonary vascular disease was present. However the PVR decreased from 9.6 to 3.6 woodunits.m2 after inspiration of 100% oxygen. We therefore performed open lung biopsy for further evaluation of the pulmonary vascular bed. The pathological findings obtained at lung biopsy indicated that there was no irreversible pulmonary vascular disease. This case was diagnosed suitable for a corrective surgery. Total repair was performed and the subsequent clinical course was satisfactory. We thus suggest that the open lung biopsy is useful to decide the surgical indication when it is difficult to determine an operative indication from hemodynamic measurement alone.

Effects of a PAF antagonist, Y-24180, on bronchial hyperresponsiveness in patients with asthma

The involvement of platelet-activating factor (PAF) in bronchial hyperresponsiveness (BHR) in bronchial asthma has been controversial. To determine whether PAF is involved in BHR in humans, we carried out a randomized, double-blind, placebo-controlled, two-phase cross-over study on the effects of Y-24180, a potent, specific, orally active PAF receptor antagonist, on BHR to methacholine in patients with asthma. The subjects were 13 patients with extrinsic stable asthma. The provocative concentration of methacholine producing a 20% fall in FEV1 (PC20-FEV1) was measured as an index of BHR. Y-24180 (20 mg twice a day) or a placebo was orally administered for 2 wk, respectively. At the time of cross-over from the first treatment regimen to the second regimen, administration of the test drug was suspended for 2 wk. The methacholine challenge test was performed four times, before and after the first treatment period and before and after the second treatment period. Compared with the placebo, Y-24180 significantly (p = 0.005) improved the PC20-FEV1 value without carryover effect and period effect by analysis of variance. These results suggest that PAF is an important mediator involved in the BHR of bronchial asthma in humans.

Extended endocardial repair of postinfarction ventricular septal rupture: new operative technique--modification of the Komeda-David operation

Between January 1992 and November 1992, four consecutive patients (ages 53 to 81 years) underwent early surgical repair of postinfarction ventricular septal ruptures using a new simple operative technique. The principles of the technique are longitudinal incision of the infarcted left anterior ventricular wall, placement of a saccular patch of single equine pericardium that covers the infarcted left ventricular wall, and large buttressed suture closure of the left ventriculotomy. The infarcted septum and infarcted left ventricular wall are completely separated from the left ventricular cavity. In this procedure, the infarcted myocardium is not resected, and left and right ventricular muscles are preserved. This technique is simple and safe for use in the acute phase of myocardial infarction, and it preserves ventricular function after surgery.

Sequential internal mammary artery grafts: clinical and angiographic assessment

Between January 1988 and August 1992, the internal mammary artery was used as a sequential graft to the left anterior descending artery and/or diagonal branch in 34 patients. One patient died in hospital. After surgery all survivors were free from angina for a follow-up of up to 4 years. Recatheterization was performed in 33 patients within 1 year of surgery. Postoperative angiography showed that 65 anastomoses (98%) were patent, but three patent grafts (5%) between the proximal and distal sequential anastomoses showed 'string sign'. It is important to prevent 'string sign' in sequential grafting. It is considered that sequential internal mammary artery grafting should be limited to coronary arteries with severe stenosis that divides anastomosed coronary arteries into two.

Anomalous origin of the left coronary artery from the pulmonary artery. New operative technique

We report a new operative technique for repair of anomalous origin of the left coronary artery from the pulmonary artery. The principles of the proposed technique are left main coronary angioplasty using a transected main pulmonary artery, side-to-side anastomosis of the aorta and newly created left coronary artery, and direct anastomosis of the transected pulmonary artery. No prosthetic material is used in this procedure. Our experience in two adults (a 35-year-old man and a 68-year-old woman) indicated that this technique permits two coronary system repair for any anatomic variation of the left coronary artery without the use of prosthetic material. This is more advantageous in infants.

[Clinical experience with continuous warm blood cardioplegia]

We applied the Continuous Warm Blood Cardioplegia (CWBC) as an approach to improve myocardial preservation. From March to June in 1992, we used the CWBC in six patients and the conventional cold crystalloid cardioplegia (CCCP) in seven patients. All of them underwent isolated coronary artery bypass grafting. There was no marked difference between the CWBC and CCCP in post operative serum level of creatine kinase (MB type), cardiac output and dose of dopamine during they weaned from cardiopulmonary bypass. All patients treated with CWBC spontaneously restored the normal sinus rhythm shortly after removal of the aortic crossclamp, which was distinct from the fact that the CCCP group showed no such recovery. This result suggest that CWBC kept high-energy phosphate level without disturbing production of ATP in myocardium. Furthermore, reperfusion injury was also likely to be prevented by CWBC.

[Coronary artery bypass surgery in patients with poor left ventricular function]

As the indications for coronary artery bypass grafting (CABG) among patients with poor left ventricular function remain incompletely defined, We undertook the study to assess the results of CABG surgery for a group of such patients. We retrospectively reviewed the clinical features and outcome for 7 patients with poor left ventricular function defined as an ejection fraction below 0.3 who underwent CABG. The mean age of the patients was 63 years (range, 38 to 78 years), and 4 were 70 years of age or older. All patients had history of previous myocardial infarction, and all had left main trunk stenosis or left main equivalent stenosis. The patients underwent CABG with three to six distal anastomoses (mean, 4.3/patient), the internal thoracic artery could be used in all patients, for one or two distal anastomoses (mean, 1.6/patient). Combined coronary endarterectomy was performed in 2 patients. With the exception of one 78-year-old patient with renal failure who died during the early postoperative period, all patients showed marked postoperative improvement in cardiac function. Cardiac catheterization and exercise stress test studies revealed significant improvement in left ventricular function and exercise tolerance in these six patients. These results suggest that excellent results can be obtained with CABG surgery in patients with poor left ventricular function when the viability of the myocardium in the bypassed area has been confirmed.

[Coronary artery bypass grafting surgery without cardiopulmonary bypass]

Improved technique in coronary artery surgery has allowed coronary artery bypass graftings (CABG) to be placed on beating heart. The effects of extracorporeal circulation and cardiac arrest are eliminated. From Jan. 1991 to June, 1992, we performed CABG surgery without cardiopulmonary bypass and cardiac arrest in 15 patients; the age ranged from 47 to 82 years with the mean of 65. Patients who had LAD and/or RCA stenosis were candidate of this procedure in early series. However in recent series, we extended the candidate to three-vessel or LMT stenosis cases who were considered ineligible for standard CABG because of renal failure or poor left ventricular function. Distal anastomoses were performed with interruption of coronary flow. From one to two distal anastomosis to the LAD and/or RCA (mean 1.4/patient) were performed. The ITA was used in all 15 patients. Combined cardiac or vascular operation was performed in 5 patients (AAA repair, TAA repair, carotid endarterectomy or coronary endarterectomy). There were no deaths and no perioperative myocardial infarction. Postoperative angiography were performed in 12 patients with a patency rate of 89%.