Relationship of Mild to Moderate Impairment of Left Ventricular Ejection Fraction With Fatal Ventricular Arrhythmic Events in Cardiac Sarcoidosis

BACKGROUND

Current guidelines recommend placing an implantable cardiac defibrillator for patients with cardiac sarcoidosis and a severely impaired left ventricular ejection fraction (LVEF) of ≤35%. In this study, we determined the association between mild or moderate LVEF impairment and fatal ventricular arrhythmic event (FVAE).

METHODS AND RESULTS

We retrospectively analyzed 401 patients with cardiac sarcoidosis without sustained ventricular arrhythmia at diagnosis. The primary end point was an FVAE, defined as the combined endpoint of documented ventricular tachycardia or ventricular fibrillation and sudden cardiac death. Two cutoff points for LVEF were used: a sex-specific lower threshold of normal range of LVEF (52% for men and 54% for women) and an LVEF of 35%, which is used in the current guidelines. During a median follow-up of 3.2 years, 58 FVAEs were observed, and the 5- and 10-year estimated incidences of FVAEs were 16.8% and 23.0%, respectively. All patients were classified into 3 groups according to LVEF: impaired LVEF group, mild to moderate impairment of LVEF group, and maintained LVEF group. Multivariable competing risk analysis showed that both the impaired LVEF group (hazard ratio [HR], 3.24 [95% CI, 1.49-7.04]) and the mild to moderate impairment of LVEF group (HR, 2.16 [95% CI, 1.04-4.46]) were associated with a higher incidence of FVAEs than the maintained LVEF group after adjustment for covariates.

CONCLUSIONS

Patients with cardiac sarcoidosis are at a high risk of FVAEs, regardless of documented ventricular arrhythmia at the time of diagnosis. In patients with cardiac sarcoidosis, mild to moderate impairment of LVEF is associated with FVAEs.

Prognostic value of estimating appendicular muscle mass in heart failure using creatinine/cystatin C

BACKGROUND AND AIMS

Heart failure with concomitant sarcopenia has a poor prognosis; therefore, simple methods for evaluating the appendicular skeletal muscle mass index (ASMI) are required. Recently, a model incorporating anthropometric data and the sarcopenia index (i.e., serum creatinine-to-cystatin C ratio [Cre/CysC]), was developed to estimate the ASMI. We hypothesized that this model was superior to the traditional model, which uses only anthropometric data to predict prognosis. This retrospective cohort study compared the prognostic value of low ASMI as defined by the biomarker and anthropometric models in patients with heart failure.

METHODS AND RESULTS

Among 847 patients, we estimated ASMI using an anthropometric model (incorporating age, body weight, and height) in 791 patients and a biomarker model (incorporating age, body weight, hemoglobin, and Cre/CysC) in 562 patients. The primary outcome was all-cause mortality. Overall, 53.4% and 39.1% of patients were diagnosed with low ASMI (using the Asian Working Group for Sarcopenia cut-off) by the anthropometric and biomarker models, respectively. The two models showed a poor agreement in the diagnosis of low ASMI (kappa: 0.57, 95% confidence interval: 0.50-0.63). Kaplan-Meier curves showed that a low ASMI was significantly associated with all-cause death in both models. However, this association was retained after adjustment for other covariates in the biomarker model (hazard ratio: 2.32, p = 0.001) but not in the anthropometric model (hazard ratio: 0.79, p = 0.360).

CONCLUSION

Among patients hospitalized with heart failure, a low ASMI estimated using the biomarker model, and not the anthropometric model, was significantly associated with all-cause mortality.

Prevalence and prognostic value of atrial fibrillation in patients with cardiac sarcoidosis

Aims

The prognostic value of the presence of atrial fibrillation (AF) in patients at the time of cardiac sarcoidosis (CS) diagnosis is unknown. This study aimed to investigate the association between AF at the time of CS diagnosis and patient prognosis.

Methods and results

This study is a post-hoc analysis of Illustration of the Management and Prognosis of Japanese Patients with CS, a multicentre, retrospective observational study that evaluated the clinical characteristics and prognosis of patients with CS. The primary endpoint was the combined endpoint of all-cause death and hospitalization due to heart failure. After excluding patients with missing data about AF status, 445 patients (62 ± 11 years, 36% males) diagnosed with CS according to the Japanese current diagnostic guideline were analysed. Compared to patients without AF, patients with AF (n = 46, 10%) had higher levels of brain natriuretic peptide and a higher prevalence of heart failure hospitalizations. During a median follow-up period of 3.2 years (interquartile range, 1.7-5.8 years), 80 primary endpoints were observed. Kaplan-Meier curve analysis indicated that concomitant AF at the time of diagnosis was significantly associated with a high incidence of primary endpoints (log-rank P = 0.002). This association was retained after adjusting for known risk factors including log-transformed brain natriuretic peptide levels and left ventricular ejection fractions [hazard ratio, 1.96 (95% confidence interval, 1.05-3.65); P = 0.035].

Conclusion

The presence of AF at the time of CS diagnosis is associated with higher incidence of all-cause death and heart failure hospitalization.

Clinical and prognostic implications of hyaluronic acid in hospitalized patients with heart failure

We investigated the clinical and prognostic implications of hyaluronic acid, a liver fibrosis marker, in patients with heart failure. We measured hyaluronic acid levels on admission in 655 hospitalized patients with heart failure between January 2015 and December 2019. Patients were stratified into three groups according to hyaluronic acid level: low (< 84.3 ng/mL, n = 219), middle (84.3-188.2 ng/mL, n = 218), and high (≥ 188.2 ng/mL, n = 218). The primary endpoint was all-cause death. The high hyaluronic acid group had higher N-terminal pro-brain-type natriuretic peptide levels, larger inferior vena cava, and shorter tricuspid annular plane systolic excursion than the other two groups. During the follow-up period (median 485 days), 132 all-cause deaths were observed: 27 (12.3%) in the low, 37 (17.0%) in the middle, and 68 (31.2%) in the high hyaluronic acid (P < 0.001) groups. Cox proportional hazards analysis revealed that higher log-transformed hyaluronic acid levels were significantly associated with all-cause death (hazard ratio, 1.38; 95% confidence interval, 1.15-1.66; P < 0.001). No significant interaction was observed between hyaluronic acid level and reduced/preserved left ventricular ejection fraction on all-cause death (P = 0.409). Hyaluronic acid provided additional prognostic predictability to pre-existing prognostic factors, including the fibrosis-4 index (continuous net reclassification improvement, 0.232; 95% confidence interval, 0.022-0.441; P = 0.030). In hospitalized patients with heart failure, hyaluronic acid was associated with right ventricular dysfunction and congestion and was independently associated with prognosis regardless of left ventricular ejection fraction.

Prognostic value of estimating appendicular muscle mass in heart failure using creatinine/cystatin C

Objectives

As heart failure with concomitant sarcopenia has a poor prognosis, simple methods for evaluating the appendicular skeletal muscle mass index (ASMI) are required. Recently, a model incorporating anthropometric data and the sarcopenia index, that is, the ratio of serum creatinine to cystatin C (Cre/CysC), was developed to estimate the appendicular skeletal muscle mass. We hypothesized that this model would be superior to the previous model, which uses only anthropometric data to predict the prognosis. This study aimed to compare the prognostic value of low ASMI as defined by the biomarker and anthropometric models in patients with heart failure.

Methods

Among 847 patients, we estimated ASMI using an anthropometric model consisting of age, body weight, and height in 791 patients and a biomarker model that incorporates age, body weight, hemoglobin, and Cre/CysC in 562 patients. Patients were divided into low and non-low ASMI groups according to the ASMI estimated by each model, using the cut-off proposed by the Asian Working Group for Sarcopenia. The primary outcome was all-cause mortality.

Results

Overall, 53.4% and 39.1% of patients were diagnosed with low ASMI by anthropometric and biomarker models, respectively. The agreement of the diagnosis of low ASMI between the two models was poor, with a kappa coefficient of 0.56 (95% confidence interval: 0.49–0.63). Kaplan-Meier curves showed that a low ASMI was significantly associated with all-cause death in both models. However, this association was retained after adjustment for other covariates in the biomarker model (hazard ratio: 2.60, p=0.003), but not in the anthropometric model (hazard ratio: 0.70, p=0.257).

Conclusions and implications

Among patients hospitalized with heart failure, a low ASMI estimated using the biomarker model, but not the anthropometric model, was significantly associated with all-cause mortality.

Funding Acknowledgement

Type of funding sources: Public grant(s) – National budget only. Main funding source(s): Japan Agency for Medical Research and Development

Genetic status of p53 and induction of apoptosis by radiation or isoflavones in human gastric carcinoma cell lines

We have shown previously that various human cancer cell lines undergo morphological changes and internucleosomal DNA fragmentation characteristic of apoptosis after exposure to ionizing radiation or isoflavones. Here, we assessed the role of p53 gene in cell cycle and apoptosis following treatment of 11 gastric carcinoma cell lines with gamma-rays, genistein, biochanin A, or daidzein. Cell survival was measured by trypan blue staining, and apoptosis was assessed by fluorochrome staining. The rate of cell survival and apoptosis of the cells by gamma-irradiation or isoflavones did not correlate with p53 gene abnormalities. Flow cytometric measurement of DNA content demonstrated that while gamma-irradiation and genistein induced G(2) arrest, biochanin A and daidzein blocked the cell cycle of all carcinoma cells at G(1) phase. At multiple time points following irradiation, G(2) arrest was observed at 12-16 h in the wild-type and mutant p53 cell lines. Induction of p53 and p21 proteins was not observed in wild-type p53 lines after exposure to gamma-irradiation or isoflavones by Western blotting. Moreover, transfection of the wild-type p53 gene into MKN-1 cells failed to induce G(1) arrest by gamma-irradiation and genistein. Based on these results, we hypothesize that gastric cancer cells may possess a signal pathway which is different from the usual mechanisms of the p53-mediated DNA damage response in normal or hematopoietic tumor cells.

Melatonin, a pineal secretory product with antioxidant properties, protects against cisplatin-induced nephrotoxicity in rats

In an attempt to define the role of the pineal secretory melatonin and an analogue, 6-hydroxymelatonin (6-OHM), in limiting oxidative stress, the present study investigated the cisplatin (CP)-induced alteration in the renal antioxidant system and nephroprotection with the two indolamines. Melatonin (5 mg/kg), 6-OHM (5 mg/kg), or an equal volume of saline were administered intraperitoneally (i.p.) to male Sprague Dawley rats 30 min prior to an i.p. injection of CP (7 mg/kg). After CP treatment, the animals each received indolamine or saline every day and were sacrificed 3 or 5 days later and plasma as well as kidney were collected. Both plasma creatinine and blood urea nitrogen increased significantly following CP administration alone; these values decreased significantly with melatonin co-treatment of CP-treated rats. In the kidney, CP decreased the levels of GSH (reduced glutathione)/GSSG (oxidized glutathione) ratio, an index directly related to oxidative stress. When animals were treated with melatonin, the reduction in the GSH/GSSG ratio was prevented. Treatment of CP-enhanced lipid peroxidation in the kidney was again prevented in animals treated with melatonin. The activity of the antioxidant enzyme, glutathione peroxidase (GSH-Px), decreased as a result of CP administration, which was restored to control levels with melatonin co-treatment. Upon histological analysis, damage to the proximal tubular cells was seen in the kidneys of CP-treated rats; these changes were prevented by melatonin treatment. 6-OHM has been shown to have some antioxidative capacity, however, the protective effects of 6-OHM against CP-induced nephrotoxicity were less than those of melatonin. The residual platinum concentration in the kidney of melatonin co-treated rats was significantly lower than that of rats treated with CP alone. It is concluded that administration of CP imposes a severe oxidative stress to renal tissue and melatonin confers protection against the oxidative damage associated with CP. This mechanism may be reasonably attributed to its radical scavenging activity, to its GSH-Px activating property, and/or to its regulatory activity for renal function.

The superiority of water-diluted 0.25% to neat 1% lidocaine for trigger-point injections in myofascial pain syndrome: a prospective, randomized, double-blinded trial

Trigger-point injection with a mixture of commercially available 1% lidocaine in sterile distilled water at a ratio of 1:3 compared with 1% lidocaine alone resulted in better efficacy and less injection pain. This simple procedure may be suitable for treatments of a wide range of myofascial pain syndromes.

Prevention of nephrotoxicity of cisplatin by repeated oral administration of ebselen in rats

The ability of ebselen, which exhibits glutathione peroxidase (GSH-Px)-like activity, to prevent cisplatin (CDDP)-induced nephrotoxicity was examined in rats. CDDP (6 mg/kg [20 micromol/kg] body weight) was injected intraperitoneally. In subgroups, daily ebselen doses of 2.75 (10 micromol), 5.5 (20 micromol), or 11.0 mg (40 micromol)/kg body weight were administrated orally 1 hour prior to CDDP treatment. Treatment with CDDP alone resulted in significantly increased plasma creatinine (Cr) and blood urea nitrogen (BUN) levels. Repeated administration of 5.5 and 11.0 mg/kg ebselen prevented the CDDP-induced elevation of plasma Cr and BUN levels and protected against kidney damage. Relative to controls, rat that received CDDP treatment displayed a decreased ratio of reduced glutathione (GSH) to oxidized glutathione (GSSG), an indicator directly related to oxidative stress, and elevated malondialdehyde (MDA) levels in the kidney. In comparison with controls, activity of GSH-Px activity, which antioxidant enzyme, was also reduced in the kidney of rats treated with CDDP. Repeated administration of 5.5 or 11.0 mg/kg ebselen prevented CDDP-induced alteration of GSH/GSSG ratios, MDA levels, and GSH-Px activity; however, no protection against CDDP was observed with administration of 2.75 mg/kg ebselen. Effective protection of CDDP-induced nephrotoxicity with ebselen was observed only when the molar amount of each daily ebselen treatment equaled or exceeded

Global brain ischemia produced by clamping left subclavian artery and bicarotid trunk in the rabbit

Thirty-five rabbits were divided randomly into 5 groups: sham operation, 10 minutes clamping bicarotid trunk (partial ischemia, PI), and 3 groups of 5, 7, and 10 minutes clamping left subclavian artery and bicarotid trunk (global ischemia, GI). Systolic arterial pressure increased slightly in the PI group, but doubled in the GI groups during clamping. Heart rate did not change in the PI group, but decreased transiently in the GI groups during clamping. Brain temperature decreased gradually in the GI groups during clamping, but did not change in the PI group. Necrotic changes were present 96 hours later in approximately 50% of the hippocampal CA1 cells in the GI groups, but in none of the cells in the PI and sham operation groups. The present results may indicate that clamping left subclavian artery and bicarotid trunk in the rabbit brings about global brain ischemia.

Highly sensitive chelating agents for histochemical staining of rare earth metals

In tissues, bromopyridylazo-diethylaminophenol has been found to be capable of staining very small amounts of rare earth metals, particularly praseodymium, terbium, dysprosium, holmium, ytterbium, and lutetium. Differentiation of a target metal from interfering metals was achieved using masking agents, polyphosphates and aminopolycarboxylic acids.

Expression of p21WAF1/CIP1 in colorectal adenomas and adenocarcinomas and its correlation with p53 protein expression

The expression of p53-inducible cyclin-dependent kinase inhibitor, p21WAF1/CIP1 in non-neoplastic mucosa, adenoma and adenocarcinoma of the colorectum was examined by immunohistochemistry and western blotting and its relation with the expression of p53 protein was analyzed. Non-neoplastic epithelial cells at the surface area showing no proliferative activity expressed p21WAF1/CIP1. The expression of p21WAF1/CIP1 was immunohistochemically detected in 55% (206/377) of the adenomas and 66% (190/289) of the adenocarcinomas, respectively. The incidence of strongly positive cases was significantly higher in the adenocarcinomas (27%) than in the adenomas (18%) (P < 0.05). The incidence of cases with strong p21WAF1/CIP1 expression was higher in stages 0, 1 and 2 carcinomas than in stages 3 and 4 carcinomas (P < 0.05). A decrease in the incidence of cases with strong expression was detected in carcinomas invading deeper than muscularis propria. The incidence of strongly positive cases was significantly lower in carcinomas with lymph node metastasis than those without metastasis (P < 0.05). The expression of p21 as well as p53 detected by western blotting was compatible with the results of immunohistochemistry in most cases examined. However, there was no significant correlation between the expression of p21WAF1/CIP1 and the abnormal accumulation of p53. These findings overall suggest that: (i) the physiological expression of p21WAF1/CIP1 may be associated with cellular senescence of colorectal mucosa; (ii) reduced expression of p21WAF1/CIP1 may participate in the progression of colorectal carcinoma; and (iii) p53-independent pathway may be considerably involved in the induction of p21WAF1/CIP1.

The efficacy of the "BURP" maneuver during a difficult laryngoscopy

The displacement of the larynx in the three specific directions (a) posteriorly against the cervical vertebrae, (b) superiorly as possible, and (c) slightly laterally to the right have been reported and named the "BURP" maneuver. We evaluated the efficacy of the BURP maneuver in improving visualization of the larynx. Six hundred thirty patients without obvious malformation of the head and neck participated in this study. We divided the degree of visualization of the larynx using laryngoscopy into five grades and compared the visualization of the larynx using the BURP maneuver with that of laryngoscopy with and without simple laryngeal pressure ("Back"). The maneuver of Back and BURP significantly improved the laryngoscopic visualization from initial inspection. The BURP maneuver also significantly improved the visualization compared with the Back maneuver. We concluded that the BURP maneuver improved the visualization of the larynx more easily than simple back pressure on the larynx.

Growth inhibitory effect of interferon-beta is associated with the induction of cyclin-dependent kinase inhibitor p27Kip1 in a human gastric carcinoma cell line

The effect of IFN-beta on cell growth and the mechanism of growth modulation was examined in human gastric carcinoma cell lines. IFN-beta inhibited the cell growth of TMK-1 cells, whereas it did not affect the growth of the other three cell lines (MKN-7, -28, and -45). The number of apoptotic cells in IFN-beta-treated TMK-1 cells was 2-fold the number of those in control TMK-1 cells, whereas the induction of apoptosis was not observed in IFN-beta-treated MKN-28 cells. IFN-beta enhanced the expression of cyclin-dependent kinase inhibitor p27Kip1 at mRNA and protein levels. The increased p27Kip1 bound preferentially to CDK6. The phosphorylation level of retinoblastoma protein in TMK-1 cells was reduced by IFN-beta treatment. IFN-beta did not affect the expression of cell cycle regulators in MKN-28 cells. These results suggest that the induction of p27Kip1 by IFN-beta might confer inhibition of cell growth, leading to subsequent apoptosis in TMK-1 cells.

Expression of cyclin-dependent kinase inhibitor p21WAF1/CIP1 in non-neoplastic mucosa and neoplasia of the stomach: relationship with p53 status and proliferative activity

The expression of the p53-inducible cyclin-dependent kinase inhibitor p21WAF1/CIP1 in non-neoplastic mucosa, adenoma, and adenocarcinoma of the stomach was examined immunohistochemically and its relationship with p53 expression and proliferative activity was analysed. In normal gastric mucosa as well as in intestinal metaplasia the epithelial cells at the surface which showed no proliferative activity expressed p21WAF1/CIP1, whereas the cells in the deep area of the glands expressing Ki-67 did not. In the neoplastic lesions, the expression of p21WAF1/CIP1 was detected in 78 per cent (112/144) of the adenomas and 76 per cent (262/343) of the adenocarcinomas. The incidence of p21WAF1/CIP1 expression did not differ among histological types of gastric carcinoma. The strong expression of p21WAF1/CIP1 was more frequently observed in carcinomas invading into submucosa or in cases of stages 2, 3, and 4 than in carcinomas limited to the mucosa or in stage 1 cases. The incidence of strongly positive cases was higher in carcinomas with lymph node metastasis than in those without metastasis. There was no apparent correlation between the expression of p21WAF1/CIP1 and the abnormal accumulation of p53 or with proliferative activity measured by Ki-67 expression. These findings overall suggest that p21WAF1/CIP1 might be associated with the senescence of non-neoplastic gastric epithelial cells; that a p53-independent pathway might be substantially involved in the induction of p21WAF1/CIP1 in gastric neoplasia; and that the proliferative activity of gastric cancer might not be solely dependent on control of the cell cycle by p21WAF1/CIP1.

Cervical sympathectomy affects adrenocorticotropic hormone and thyroid-stimulating hormone in rats

To examine the effects of bilateral cervical sympathectomy on the secretion of adrenocorticotropic hormone (ACTH), thyroid-stimulating hormone (TSH), growth hormone (GH), and prolactin (PRL), 18 male rats were divided into three groups: control (Cont), sham operation (Sham), and bilateral cervical sympathectomy (Symp). All rats were kept under a normal circadian rhythm for 2 weeks. Subsequently, blood was collected and plasma ACTH as well as serum TSH, GH, and PRL levels were measured. The difference in ACTH levels between the Cont and Sham groups was not significant, but ACTH levels in the Symp group were significantly higher than those in the other groups. The difference in TSH levels between the Cont and Sham groups was also not significant, but TSH levels in the Symp group were significantly lower than those in the Cont group. There were no statistically significant differences in GH and PRL levels among these groups. The present results suggest that cervical sympathectomy in the rat increases ACTH secretion and decreases TSH secretion in the pituitary. These effects seem to be due to a mildly increased secretion of melatonin in the pineal body that probably in turn increases corticotropin-releasing factor (CRF) secretion and decreases thyrotropin-releasing hormone (TRH) secretion in the hypothalamus. Extrapolation of these findings to humans suggests that longterm and repeated stellate ganglion block would affect the pituitary secretions of ACTH and TSH.

Genetic status and expression of the cyclin-dependent kinase inhibitors in human gastric carcinoma cell lines

Deregulation of cyclin, cyclin-dependent kinases (CDKs) and their inhibitors could have a pivotal role in the development of diverse human cancers. We examined the genetic status and the expression of CDK inhibitors (p21, p27, p16 and p15), CDK2 and cyclins (A, D1 and E) in eight gastric carcinoma cell lines, in comparison with the status of p53 gene alterations. All the cell lines (except MKN-28) that contained a p53 gene abnormality expressed very low or undetectable levels of p21 mRNA, while the cell lines (MKN-45 and -74) with wild-type p53 gene expressed high levels of p21 mRNA. An inverse correlation was found between the level of p21 mRNA and the expression of mRNAs for CDK2 and G1 cyclins. MKN-28 was an exception; it contained mutated p53, and expressed mRNAs for p21, CDK2 and G1 cyclins at high levels. Only MKN-45 and -74, with wild-type p53, expressed considerable levels of p21 protein. Homozygous deletion of the p16 and p15 genes was detected in two (MKN-45 and HSC-39) of the eight gastric carcinoma cell lines, p16 protein was not expressed in three cell lines (MKN-28, MKN-74 and KATO-III), as well as MKN-45 and HSC-39. Rearrangement of the p15 gene was found in TMK-1. Rearrangement of the p27 gene was detected in MKN-45, although the expression of p27 protein was well preserved in all the gastric carcinoma cell lines. The expression of pRb was also preserved in all the cell lines except KATO-III. No obvious correlation was observed between the p53 gene status and the expression of p27 and p16. These findings suggest that abnormal regulation of CDK2/cyclins and CDK inhibitors might be involved in deregulated growth of gastric carcinomas.

Inhibition of cell growth by transforming growth factor beta 1 is associated with p53-independent induction of p21 in gastric carcinoma cells

Cell cycle regulators such as cyclins, cyclin-dependent kinases (cdks) and their inhibitors control the growth of cells. SDI1/CIP1/WAF1/p21 is a potent inhibitor of G1 cdks, whose expression is induced by wild-type p53. To elucidate the mechanism of growth inhibition by transforming growth factor beta 1 (TGFbeta 1), we examined the effect of TGFbeta 1 on the expression of p21, G1 cyclins and cdks by human gastric cancer cell lines. TGFbeta 1 induced p21 expression and subsequently suppressed cdk2 kinase activity, followed by a reduction in phosphorylation of the product of the retinoblastoma tumor suppressor gene in TMK-1 cells, which are responsive to TGFbeta 1. Coimmunoprecipitation analysis demonstrated that TGFbeta 1 increased the level of p21 protein present in complexes with cdk2. In contrast, TGFbeta 1 did not induce p21 in TGFbeta 1-resistant MKN-28 cells. TGFbeta 1 did not affect the levels of p53 mRNA and protein in TMK-1 and MKN-28 cells, which contain mutated p53 genes. These mutated p53 complementary DNAs, when overexpressed, failed to activate transcription from the p21 promoter. Furthermore, TGFbeta 1 caused a reduction in the steady-state level of cyclin A protein concomitantly with inhibition of cdk2 kinase activity in TMK-1 cells. These results suggest that the growth inhibition of tumor cells by TGFbeta 1 is associated with p53-independent induction of p21, subsequent suppression of cdk activity and a decrease in cyclin A protein in TMK-1 cells.

Expression of cyclin E in human gastric adenomas and adenocarcinomas: correlation with proliferative activity and p53 status

The expression of cyclin E in human gastric adenomas and adenocarcinomas was examined immunohistochemically to elucidate the role of cyclin E in stomach carcinogenesis. The expression of cyclin E was detected in 49% (90/182) of the adenomas and 59% (260/439) of the adenocarcinomas. The incidence of strongly positive cases (overexpression of cyclin E) was significantly higher in the adenocarcinomas (29%; 128/439) than in the adenomas (4%; 8/182) (p < 0.01). The incidence of the cyclin E expression showed a tendency to be higher in deeply invasive carcinomas and in the cases with lymph node metastasis, while the incidence did not differ among histological types. The expression of cyclin E was significantly correlated with the proliferative activity of the tumor cells measured by KI-67 antigen expression (p < 0.01). It was also correlated with the abnormal accumulation of p53 protein in the tumor cells (p < 0.01). These results suggest that overexpression of cyclin E and subsequent deregulation of the cell cycle may confer the development and progression of the gastric carcinomas.

Concurrent amplification of cyclin E and CDK2 genes in colorectal carcinomas

The genetic changes of cyclin A, DI, E and CDK2 were examined in human colorectal carcinomas by Southern-blot analysis. Gene amplification of cyclin E was detected in 5 of 53 (9.4%) primary colorectal carcinoma tissues. Interestingly, in 3 of 5 tumors showing cyclin E gene amplification, the CDK2 gene was amplified simultaneously with rearrangements. No obvious correlation was detected between gene amplification and clinicopathological features of colorectal carcinomas. Out of 7 colon carcinoma cell lines, 2 showed gene amplification of cyclin E without gene amplification of CDK2. No amplification of cyclin A or DI gene was found in any of the colorectal carcinoma tissues or colon carcinoma cell lines. Our results suggest that the concurrent amplification of cyclin E and CDK2 genes may play a role in colorectal carcinogenesis.

Frequent amplification of the cyclin E gene in human gastric carcinomas

We searched for genetic alterations of the cyclin D1 and cyclin E genes in 45 human gastric carcinoma tissues. Expression of cyclin E mRNA and protein was also analyzed in eight of them by Northern and Western blots and immunohistochemical staining. The cyclin E gene was amplified 3-10 fold in seven gastric cancer tissues (15.6%), of which six were advanced gastric cancers. All of the cases with the cyclin E gene amplification displayed lymph node metastasis. Moreover, the case with the gene amplification overexpressed the cyclin E mRNA and protein. One of eight gastric cancer cell lines, MKN-7, shared the cyclin E gene amplification, and all of the gastric cancer cell lines expressed high levels of the cyclin E mRNA and protein even without gene amplification. Amplification of the cyclin D1 gene was not observed in any of the gastric carcinoma tissues or gastric carcinoma cell lines. These results suggest that the gene amplification and overexpression of cyclin E play an important role in the abnormal growth and progression of gastric carcinoma.

[Expression of sdi1, a potent inhibitor of cdk2 kinase, cdk2 and G1 cyclins and mutation of sdi1 in human gastric carcinomas]

Sdi1, also known as Cip1/Waf1, is a potent inhibitor of G1 cyclin-dependent kinases, which is induced by wild type p53 but not by mutant p53. Expression of mRNAs for sdil, cdk2 and G1 cyclins was examined in gastric carcinomas. All the cell lines expressing very low or undetectable level of sdil mRNA contains p53 gene abnormalities, while the cell lines expressing high level of sdil shares wild type p53 gene. An exception was a cell line MKN-28 with mutated p53 gene which expressed mRNAs for sdi1, cdk2 and G1 cyclins at high levels, p21 point mutation was detected in one (MKN-28) of the eight cell lines. These result suggest that low level of sdil and subsequent overexpression of cdk2 and G1 cyclins might be involved in deregulated growth of gastric carcinomas. It is likely that gene alteration of sdil and subsequent loss of function may have implication for cdk2 and G1 cyclins expression.

[Anesthetic management of two patients with mitochondrial encephalopathy, lactic acidosis and stroke-like episodes (MELAS)]

MELAS is a type of the mitochondrial myopathy characterized by elevation of pyruvate and lactate levels in both the blood and cerebrospinal fluid. This syndrome frequently accompanies cerebral infarction like symptoms. Recently, we experienced two patients for anesthesia with MELAS (both 11-year-old girls). V-P shunt construction and IVH reservoir implantation were conducted, respectively. Anesthesia was induced with fentanyl and midazolam, and vecuronium was used to facilitate tracheal intubation. Volatile anesthetic was avoided, and anesthesia was maintained with fentanyl, midazolam, and nitrous oxide. Arterial blood gases and pH were frequently checked, and acetated electrolyte solution was infused mainly during surgery. No complications occurred during anesthesia in both patients. In the anesthetic management for MELAS, measures to prevent malignant hyperthermia must also be considered.

[Use of ketamine combined with local anesthetics in epidural anesthesia]

Postoperative pain relief and sedation with epidural ketamine were studied. Twenty-four patients for elective upper abdominal surgery were divided into 4 groups. Epidural catheter was inserted into thoracic epidural space before induction of general anesthesia. In each group, either 0.25% bupivacaine 5 ml only, ketamine 0.1 mg.kg-1 + bupivacaine 5 ml, or ketamine 0.3 mg.kg-1 + bupivacaine 5 ml, or ketamine 0.5 mg.kg-1 + bupivacaine 5 ml was injected into epidural catheter for complaint of pain in recovery room. In ketamine injected groups, blood pressure and heart were unchanged, but respiration rate increased significantly. Patients in ketamine 0.3 or 0.5 mg.kg-1 injected groups, pain relief and sedation score were significantly intensified, but patients in ketamine 0.5 mg.kg-1 injected group, incidence of pain in the back during injection and headache was high. We conclude that epidural ketamine is useful for postoperative pain relief, and the superior dose of epidural ketamine is 0.3 mg.kg-1.

Expression of e-cadherin, alpha-catenins and Beta-catenins in human gastric carcinomas - correlation with histology and tumor progression

The expression of cell-cell adhesion molecule, E-cadherin and its associated proteins, alpha- and beta-catenins in human gastric carcinomas was examined by Western blotting. All the seven gastric carcinoma cell lines expressed E-cadherin except KATOIII, which was derived from pleural effusion of a scirrhous type stomach cancer or Borrmann's type-4 carcinoma. The expression of alpha-catenin was not detected in HSC43 derived from scirrhous carcinoma, while HSC39 expressed abnormal beta-catenin caused by genetic alteration. In gastric carcinoma cases, the levels of E-cadherin and alpha-catenin were significantly lower in poorly differentiated adenocarcinomas and scirrhous carcinomas when compared to other types of gastric carcinomas. Deeply invasive carcinomas expressed E-cadherin and alpha-catenin at lower levels. However, the expression level of alpha-catenin was not necessarily consistent with that of E-cadherin. One of 10 gastric carcinomas examined showed complete deletion of alpha-catenin gene in Southern blotting. beta-catenin was expressed at lower level in poorly differentiated adenocarcinomas than in well-differentiated adenocarcinomas. These findings suggest that reduction in the expression of E-cadherin and its associated molecules, catenins, is involved in the development and infiltrative growth of scirrhous type gastric carcinomas.

Frequent loss of heterozygosity of the long arm of chromosome 7 is closely associated with progression of human gastric carcinomas

Loss of heterozygosity (LOH) on the long arm of chromosome 7 was examined using 5 polymorphic marker probes on 98 gastric carcinomas to elucidate a novel locus for development and progression of the tumors. Twenty-six (32%) of 82 informative cases showed LOH on 7q on at least one locus of 5 loci. Among 5 loci, LOH at D7S95 locus was most frequent, the incidence being 53% in well-differentiated gastric carcinomas and 33% in poorly differentiated and scirrhous gastric carcinomas respectively. At 3 loci, c-met, D7S63 and D7S22, the incidence of LOH was about 30% and 10% in well-differentiated and poorly differentiated gastric carcinoma cases respectively. In contrast, LOH at D7S64 was not detected in any gastric-carcinoma cases. Deletion mapping of 7q revealed that D7S95 locus was the essential region of LOH. Eight (62%) of 13 cases with LOH at D7S95 locus belonged to the most advanced stage grouping. Furthermore, 6 (75%) of 8 cases with abdominal dissemination showed LOH at D7S95. Therefore, cases with LOH at D7S95 showed significantly worse prognosis than the cases without the LOH in the stage-III and stage-IV groups. These findings overall suggest that D7S95 locus on 7q may contain a candidate suppressor gene for the progression of gastric carcinoma.

[Problems of epidural droperidol administration]

We describe three cases of extrapyramidal reactions apparently caused by epidural administration of droperidol. These patients suffered from chronic pain and was treated with epidural lidocaine and droperidol. Two patients received continuous administration of droperidol, and experienced acute dystonia and another after a single dose, developed akathisia. Adverse reactions occurred at 15, 20 and 24 hours after the administration of droperidol. The first patient received droperidol 6 mg, the second 8.5 mg and the third 5 mg. We consider that extrapyramidal reactions are due to overdoses because the patients who had been given less than 2.5 mg of droperidol a day, showed no adverse reaction. Although we use higher doses with NLA or for management of fever than with epidural administration of droperidol, we seldom encounter cases of side effects with droperidol. Epidurally administrated droperidol spreads rostral within the neuraxis and causes delayed extrapyramidal reactions as epidural morphine develops delayed respiratory depression. We must be careful in caring patients suffering from chronic pain with continuous epidural administration of droperidol.

[Amount of mercury from dental amalgam filling released into the atmosphere by cremation]

Mercury in dental amalgam filling is released into the atmosphere by cremation and is a suspected source of mercury pollution. The amount of mercury released was measured at three crematoriums. First, mercury levels in the atmosphere were measured. Mercury existed mainly in the gaseous form in ambient air. The concentration of atmospheric mercury at the three crematoriums (S, T and M) ranged from 4.3 to 19.7ng/m3, which was nearly identical to levels in our university surveyed as the control area and also to the levels of atmospheric mercury in general in Japan. Secondly, the amount of mercury release from T crematorium was estimated using official published statistical data in Japan and calculated as follows: sigma[(age specific number of dead that were cremated) x (the number of restored teeth by age category) x (mercury content per amalgam filling (0.6 g))] x (prevalence rate of restoration with amalgam). The amount of mercury released from this crematorium was estimated to be approximately 9.4 kg per year, or a daily release of 26 g into the ambient air. These results indicate that mercury release by cremation is similar to that from other man-made sources.

Interpleural block for patients with multiple rib fractures: comparison with epidural block

Interpleural block (IPB) was compared with epidural block (EB) in 17 adults with unilateral multiple rib fractures and hemopneumothorax. The study was a randomized, crossover, before-after trial on the first and second hospital days. An IPB catheter was inserted along with a chest tube, and an upper thoracic EB was also established in the same patient. We administered 10 ml of 1% lidocaine for both blocks. The range of thermohypesthesia was unilateral and shorter in IPB, whereas it was bilateral and wider in EB. The effects of pain relief were almost the same. Respiratory rate decreased, and PaO2 tended to elevate similarly. In IPB, systemic blood pressure changed minimally, but it fell significantly in EB, which would be a disadvantage of EB in trauma patients. Serum levels of lidocaine were similar and in the safe range. The technique of IPB seemed to be easier than EB. In conclusion, IPB with lidocaine is as effective for pain relief as EB.

Clavicular approach to intraosseous infusion in adults

We attempted a clavicular approach to intraosseous infusion (clavicular IO) as a new procedure in adults, and compared the flow rates of subclavian venous infusion, and clavicular, iliac and tibial IO. Furthermore, we observed enhanced roentgenograms of each IO by contrast media. As a result, clavicular IO indicated 11.9 +/- 0.68 mL/kg/hr (mean +/- SD, n = 29), iliac IO 32.2 +/- 4.48 (n = 21), tibial IO 18.9 +/- 1.28 (n = 15), and subclavian venous infusion 15.2 +/- 1.48 (n = 15). There were no statistically significant differences between subclavian venous infusion and clavicular IO. In roentgenograms, the contrast media entered the inferior vena cava from iliac IO, and via the femoral vein by tibial IO. The superior vena cava was enhanced through the subclavian vein in clavicular IO. No complications such as fractures or transclavicular penetrations by the IO needle occurred. In conclusion, clavicular IO may be an alternative infusion technique to provide the fluids into the subclavian vein in adults.

Systematic management of graft-versus-host disease (GVHD)

Patients with graft-versus-host disease (GVHD) develop multiple organ failure (MOF), so systematic management is needed. First, patients should be kept in a clean room. Antibiotics, anti-fungal drugs and gamma-globulins are essential for the prevention and treatment of infections. If patients are hypoxic for the nasal cannula or the mask, continuous positive airway pressure (CPAP) or artificial ventilation must be used. In the treatment of hepatic dysfunction, lactulose, branched chain amino acid, glucagon-insulin, and Prostaglandin E1 (PGE1) are given. If plasma exchanges are ineffective, a bilirubin absorption therapy may remain partially effective. In the treatment of renal failure, diuretics, PGE1 and dopamine are given. Hemofiltration and hemodialysis will be effective. But the effective treatment for post-transfusion GVHD is unavailable, so systematic management of GVHD is no more than allopathic treatment.

[P50, 2,3-diphosphoglycerate and sodium as well as potassium in red blood cells in the perioperative period after hemodilutional autotransfusion]

The changes of the P50, 2,3-DPG and sodium as well as potassium of red blood cells in perioperative period were studied in 12 patients who underwent hemodilutional autotransfusion (HAT). P50 and 2, 3-DPG did not show remarkable changes before the third day after operation, but increased significantly on 5th and 7th day. There was a positive correlation between P50 and 2,3-DPG. Potassium of red blood cell increased significantly except on the first day. But sodium of red blood cell showed no remarkable change. In conclusion, our data demonstrate that the tissue oxygen supply from the red blood cell is maintained, because P50 did not decrease. Sodium in the red blood cell does not show remarkable changes, and therefore the membrane function of the red blood cell should be kept intact.

[Intrapleural regional analgesia in pain management after chest trauma]

Twelve chest trauma patients with severe pain were studied. All of them had multiple rib fractures, hemopneumothorax or pulmonary contusion, and needed the continuous chest drainage. 16 G epidural block catheter was introduced 20 cm into the apex of the pleural space. Furthermore, another catheter was placed into the base of the pleural space. After injecting 1% lidocaine 10 ml, the analgesic effect, the analgesic range according to injected point (apex or base), and the changes of vital signs, PaO2/FIO2 and PaCO2 were evaluated. The average pain scale before interpleural regional analgesia (IPA) was 2.9 and 1.0 after 15 min. The time to return to pre-IPA condition took about 150 min. The mean blood pressure did not show significant changes, although pulse and respiratory rate decreased. PaCO2 did not show significant changes, although PaO2/FIO2 increased significantly. The present study indicates that IPA in chest trauma reduces pain and improves PaO2/FIO2 significantly without circulatory changes. It was reported that it was difficult to obtain effective pain relief after thoracotomy. However, when the catheter is placed at the apex, it seems to be effective to relief pain on the chest site. In conclusion, IPA seems to be simple, effective and useful to remove pain from chest trauma when epidural block is difficult to induce.

[Study of combined hepatocellular and cholangiocarcinoma]

Four patients with combined hepatocellular and cholangiocarcinoma were studied. One case received hepatic arterial infusion therapy (HAIT), 2 hepatectomy and the case with extrahepatic cholangiocarcinoma underwent enucleation. According to Allen's classification, two were combined type and the others mixed type. Tumor ploidy patterns on flow cytometric DNA analysis were aneuploid in 2 cases with curative resection, of which one is still alive 6 years and 3 months after surgery. It suggested that the patient's survival was affected by the pathological factors more than the ploidy patterns of the tumor. A case treated by HAIT improved considerably in terms of symptoms and evidenced reduction in the size of the deposits. Selection of anticancer agents sensitive to both hepatocellular and cholangiocarcinoma is required.

[Predicting the difficulty of laryngoscopy using the distance between the lower border of the mandible and the thyroid notch]

We examined the relationship between the degree of difficulty in visualization of the larynx and the distance from the lower border of the mandible to the thyroid notch (M-T distance). Patients were examined and the M-T distance was measured with their neck fully extended during preoperative period. Difficulty of laryngoscopy was graded as reported previously. Five hundred sixty one patients were assessed, and those with obvious neck and head pathology were excluded. There were 440 cases (78.4%) in grade 1, 116 cases (20.7%) in grade 2 and only 5 cases (0.9%) in grade 3. There were no grade 4 cases. The M-T distance was 5.4 +/- 0.6 cm in grade 1, 4.6 +/- 0.7 cm in grade 2 and 3.6 +/- 0.7 cm in grade 3. These were significantly different with each other (P < 0.05). If the M-T distance is 4.5 cm or less, the difficulty in visualization of laryngoscope increases. Therefore, in the case in which the M-T distance is 4.5 cm or less, we recommend further examination and preparation for difficult laryngoscopy.

[Clinical examination of acetated Ringer solution in patients with normal liver function and those with liver dysfunction]

Acetated Ringer solution (AR) was studied clinically to find its usefulness in patients with liver dysfunction compared with lactated Ringer solution (LR). The thirty-eight patients scheduled to be operated were divided into four groups (Group I: with normal liver function and AR infused, Group II: with normal liver function and LR infused, Group III: with liver dysfunction and AR infused, Group IV: with liver dysfunction and LR infused). AR or LR was administered to each group at a speed of 10 ml.kg-1.h-1, and we investigated the differences of these four groups clinically. L-lactic acid increased significantly in all groups after administration of AR or LR. D-lactic acid increased in LR groups, and acetic acid increased in AR groups. However, the other parameters, including the acid-base balance, electrolytes and liver function, showed no significant changes in any group. Therefore the status of liver dysfunction did not affect the metabolism of lactic acid in this study. These findings indicate that as an intraoperative fluid, AR is just as useful as LR. However, there was no significant difference between the data of AR groups compared with those of LR groups. In conclusion, AR is not necessarily a better fluid compared with LR as an intraoperative fluid in patients with liver dysfunction.

[A study of postoperative respiratory function]

The purpose of this study is to investigate the causes of postoperative respiratory failure from the point of view of respiratory movement and respiratory function, using a respigraph. Thirty patients who had laparotomy, thoracotomy or both were studied. A-aDo2 increased after operation. The values recovered slowly in the order of thoracotomy, laparotomy, was thoraco-laparotomy group. Percent vital capacity (% VC), one second timed force expiratory volume (FEV1), and peak expiratory flow (PEF) were suppressed immediately after operations and increased slowly, but showed still lower values even on the 7th day. VT, V min, f, TI/TT, VT/TI and PaCO2 were almost at the same levels among the three groups. Percent rib cage (% of RC) increased and remained high on the 7th day after laparotomy and thoraco-laparotomy, but showed no remarkable changes after thoracotomy. Between A-aDo2 and % RC in laparotomy group, there was a good correlation. Not only FRC but also the change of % RC seemed to have caused postoperative hypoxemia. The movement of the abdomen affected respiratory dysfunction more than the movement of the thorax after thoracic and abdominal surgery.

[Effects of mannitol on the function of red blood cells]

The effects of mannitol on the function of red blood cell were studied in 12 neurosurgical patients for 4 hours after intravenous administration of 2 g.kg-1 mannitol taking 30 min. After the administration of mannitol, osmotic pressure, Na and K in serum and of red blood cell were all altered. P50, 2, 3-DPG rose gradually and red blood cell deformity improved significantly. These results indicate that mannitol can shift oxyhemoglobin dissociation curve rightward, improve red blood cell deformity, and increase tissue oxygenation significantly. Mannitol administration not only decreases intracranial pressure but also improves peripheral circulation and oxygen transport during brain resuscitation.

[Change of renal function immediately after angiography]

Abdominal angiography using ioxaglate (3.0-4.5 ml/kg) was performed in 10 patients with normal renal function. Ccr, FENa, CH2O were compared before and immediately after angiography. There was no significant change in Ccr and CH2O level, while FENa increased remarkably after angiography. This study suggested that the osmotic diuresis and the proximal tubular stress were induced by administrated low osmolality contrast material during conventional abdominal angiography.