The utility of a novel approach to quantify dyssynchrony by multidetector computed tomography

Funding Acknowledgements

Type of funding sources: None.

Background

Quantification of left ventricular (LV) dyssynchrony is of great interest for resynchronization therapy (CRT). Recently, cardiac computed tomography (CCT) is feasible for evaluation of dyssynchrony. Our aim was to assess a novel simplified approach using CCT to quantify LV dyssynchrony.

Methods

We studied 346 consecutive patients with a wide range of QRS width and ejection fractions (EF). Electrocardiogram-gated contrast-enhanced 256-slice multidetector CT (Brilliance 256 iCT, Philips Medical Systems) was performed before CRT. After CCT scan, the LV endocardial boundaries from short-axis images reconstructed at 5% increments of cardiac cycle were automatically detected, and a time from R-wave to maximal wall motion was calculated for each of the 16 standardized segments for all slices using software "Myocardial Contraction Map" (Argus, Inc Ehime, Japan). The standard deviation of all segments modified by mean heart rate (%SD) was respectively calculated as the global parameter of dyssynchrony. LVEF was also measured using MDCT.

Results

%SD was feasible in all patients, respectably. %SD was significantly different between the different QRS duration groups; narrow QRS (<120ms): 9 ± 5%, relatively wide QRS (120-150 ms): 11 ± 6%, and significantly wide QRS (>150 ms): 14 ± 7% (p <0.001). Moreover, there was significantly difference in %SD between the different morphology groups; normal: 9 ± 7%, Non-left bundle branch block (Non-LBBB): 10 ± 6%, LBBB: 17 ± 7% (p <0.001).

Conclusion

This novel simplified approach by CCT can quantify dyssynchrony in different QRS duration and morphology groups. This method has promise for clinical applications to the evaluation of patients for CRT.

Abstract Figure.

Quantitative analysis of dyssynchrony assessed by multidetector computed tomography can predict clinical outcome after cardiac resynchronization therapy

Background

The degree of mechanical dyssynchrony has been suggested as a predictor for long-term survival after cardiac resynchronization therapy (CRT). There have been little reports of dyssynchrony assessment with the use of cardiac computed tomography (CCT).

Methods

We studied 35 heart failure (HF) patients (average age 67±10 years) referred for CRT with NYHA III-IV heart failure, left ventricular (LV) ejection fraction (EF) 20±10% (all ≤35%), and QRS duration 156±22 ms (all ≥120ms). Electrocardiogram-gated contrast-enhanced 256-slice multidetector CT was performed before CRT. Based on CCT, the LV endocardial boundaries from short-axis images reconstructed at 5% increments of cardiac cycle were automatically detected, and the time from R-wave to maximal wall motion was calculated for each of the 16 standardized segments for all slices using software “Myocardial Contraction Map”. The standard deviation modified by mean heart rate (%SD) was respectively calculated as the global parameter of dyssynchrony. LVEF was also measured using MDCT. The predefined primary end-point was the first HF hospitalization or death over 2 years.

Results

%SD was feasible in all patients, respectably. There were 16 events over 2 years; 11 HF hospitalizations and 5 deaths. Patients with %SD ≥22% (optimal cutoff for outcome by ROC curve analysis) had a better clinical outcome than patients with %SD <22% (p=0.01, Figure).

Conclusion

Patients who had %SD ≥22% assessed by MDCT had a particularly favorable event-free survival following CRT, and this appears to be an important prognostic marker.

Funding Acknowledgement

Type of funding source: None

P3587Tip detection method using the new short-tip IVUS with pull-back system which facilitates the 3D wiring technique in percutaneous coronary intervention for chronic total occlusion

Background

The strategy of intravascular ultrasound (IVUS)-guided wiring for CTO PCI, that is, leading the second guidewire into the true lumen under observing by IVUS from subintimal space, is the last resort. We developed the angiography-based 3D wiring method. During establishment of the angiography-based 3D wiring method, we deduced that observation of the guidewire tip as well as the shaft named “The tip detection method” simplifies and facilitates 3D wiring under IVUS-guided wiring. Therefore, we produced New CTO IVUS which is the upgraded version of Navifocus WR IVUS by adding the pull-back transducer system. This pull-back system enables us to detect the tip as well as the shaft of the second guidewire in real time (tip detection method), which facilitates the 3D wiring technique under IVUS-guided wiring.

Objective

We evaluated the efficacy of the tip detection method during 3D wiring for CTO PCI with New CTO IVUS.

Method

We created a target pinpoint penetration model and performed the procedures using an experimental heartbeat model. The target (a tube with a lumen 0.6 mm in diameter) was placed in the distal part of a CTO 20 mm in length made of 2.5% agar. After the second guidewire (Conquest-12g) was advanced into the CTO lesion to within 5mm of the target using the angiography-based wiring, IVUS-guided wiring was performed by using Navifocus WR or New CTO IVUS each five times.

Result

The frequency of the puncture time was reduced using the new CTO IVUS compared to the Navifocus WR (1.7±0.8 vs. 28.8±23.2, p=0.17). The procedure time was significantly shorter using the new CTO IVUS compared to the Navifocus WR (103±61 vs. 459±373 seconds, p=0.04).

Conclusion

The tip detection method during 3D wiring with the new short tip IVUS with the pull-back system enables us to easily perform 3D wiring and will change the CTO PCI strategy.

Efficient luminescent properties and cation recognition ability of heavy group 13 element complexes of N2O2- and N2O4-type dipyrrins

Heavy group 13 element complexes of N₂O₂- and N₂O₄-type dipyrrins exhibited efficient luminescent properties and cation recognition ability.

Tissue Factor Pathway Inhibitor Inhibits Aortic Smooth Muscle Cell Migration Induced by Tissue Factor/Factor VIIa Complex

Tissue factor (TF), a transmembrane glycoprotein, forms a high affinity complex with factor Vll/VIIa (FVIIa) and thereby initiates blood coagulation. Tissue factor pathway inhibitor (TFPI) is an endogenous protease inhibitor of TF/FVIIa-initiated coagulation. We previously reported that TF was a strong chemotactic factor for cultured vascular smooth muscle cells (SMCs). In this study, we examined the contribution of FVIIa and the effect of TFPI to TF-induced cultured SMC migration. TF/FVIIa complex showed a strong migration ability, however, neither TF alone nor FVIIa induced SMC migration. TF/FVIIa treated by a serine protease inhibitor and the complex of TF and inactivated FVIIa (DEGR-FVIIa) did not stimulate SMC migration. Pretreatment with hirudin and the antibodies to a-thrombin and factor X had no effect on TF/FVIIa-induced SMC migration, although a-thrombin and factor Xa also induced SMC migration respectively. TFPI markedly inhibited TF/FVIIa-induced SMC migration in a concentration-dependent manner, but did not affect the SMC migration induced by platelet-derived growth factor (PDGF)-BB, basic fibro blast-growth factor (bFGF), or a-thrombin. These results indicate that the catalytic activity of TF/FVIIa complex is important on SMC migration, and TFPI can reduce SMC migration as well as thrombosis.

Tissue Factor Induces Migration of Cultured Aortic Smooth Muscle Cells

Tissue factor (TF) plays a key role as a primary initiator on the extrinsic coagulation cascade. Recently, upregulation of TF has been reported in human atherosclerotic lesions. We investigated the effects of TF on migration and proliferation of cultured smooth muscle cells (SMCs) from rabbit aortas. We tested three kinds of recombinant human TF (L-TF: the full length of TF with relipidation, NL-TF: the full length of TF without relipidation, and S-TF: a soluble form of TF1-219). Only L-TF had coagulant activity. All kinds of TF showed the chemotactic migration activity for SMCs. The migration ability of TFs was comparable to those of platelet-derived growth factor (PDGF)-BB and basic fibroblast-growth factor (bFGF), and was inhibited by anti-TF polyclonal and monoclonal antibodies. On the other hand, none of the forms of TF induced SMC proliferation. These results indicate that TF is not only a coagulation factor but also a strong chemotactic factor for vascular SMCs, and suggest that TF could play an important role in atherogenesis as well as in hemostasis and thrombosis.

Fibrin-Rich and Platelet-Rich Thrombus Formation on Neointima: Recombinant Tissue Factor Pathway Inhibitor Prevents Fibrin Formation and Neointimal Development following Repeated Balloon Injury of Rabbit Aorta

Thrombus formation and neointimal growth are the critical events in restenosis after balloon angioplasty. However, the responses of diseased vessels to injuries caused by balloon angioplasty have not been well examined. We investigated the thrombus formation and neointimal development following the balloon injury to the previously induced neointima in the rabbit aorta and the effects of recombinant tissue factor pathway inhibitor (rTFPI) on these responses. Rabbit thoracic aortas were subjected to injury with a Fogarty 4F balloon catheter at 1.75 atm (first injury), and 4 weeks later the same vessels were subjected to the second injury with a Swan-Ganz 5F balloon catheter at 1.4 atm (mild-injury group) or 1.8 atm (severe-injury group), and immediately after that a retrograde bolus injection of rTFPI (100 μg/kg body weight) or saline was performed into the injured segments via the central tube of the Swan-Ganz catheter. Twenty minutes after the second injury, the injured surfaces were covered with platelet-rich thrombi in the mild-injury group and with fibrin-rich thrombi in the severe-injury group. Damaged intimal smooth muscle cells, which were immunohistochemically positive for tissue factor (TF), were observed beneath the fibrin-rich thrombi. The neointima 4 weeks after the second injury was significantly thicker in the severe-injury group than in the mild-injury group. The bolus infusion of rTFPI markedly inhibited fibrin formation on the injured surfaces, and significantly reduced the neointimal development in the severe-injury group at 4 weeks after the second injury. These results indicate that TF-dependent coagulation pathway is primarily responsible for fibrin-rich thrombus formation and may play an important role in neointimal development following the balloon injury to the rabbit aortic neointima. Additionally the bolus administration of rTFPI to the injured vessels could prevent mural thrombus formation and neointimal growth after balloon angioplasty.

Proportion of fibrin and platelets differs in thrombi on ruptured and eroded coronary atherosclerotic plaques in humans

OBJECTIVE

To determine the proportion of platelets and fibrin in coronary thrombi.

DESIGN

Immunohistochemical and morphometric means to examine the coronary arteries of 31 patients who died of acute myocardial infarction.

RESULTS

Fresh thrombi were detected in the feeding arteries of infarction areas in 23 cases (74%) and were associated with plaque rupture in 18 (78%) and plaque erosion in 5 (22%). An immunohistochemical study showed that the thrombi consisted of a mixture of fibrin and platelets as well as some other types of blood cells. The fibrin and platelet positive areas in the thrombi associated with plaque rupture accounted for 74 (19)% and 35 (20)% (p < 0.01) and those associated with erosion accounted for 51 (6)% and 70 (21)%, respectively, of the total areas. Areas of positive immunoreactivity for tissue factor and C reactive protein were also significantly greater in ruptured than in eroded plaques.

CONCLUSION

These results indicate that the proportions of fibrin and of platelets differ in coronary thrombi on ruptured and eroded plaques. Higher proportions of tissue factor and C reactive protein contribute more significantly to thrombus formation on plaque rupture than on plaque erosion.

Increased Vascular Wall Thrombogenicity Combined With Reduced Blood Flow Promotes Occlusive Thrombus Formation in Rabbit Femoral Artery

OBJECTIVE

Plaque disruption does not always result in complete thrombotic occlusion. The mechanism of arterial thrombus propagation remains unclear.

METHODS AND RESULTS

We studied how vascular wall thrombogenicity and blood flow reduction affect thrombus propagation using a rabbit model of single and repeated balloon injury. After balloon injury of the normal femoral artery, the blood flow was reduced to 50%, 25%, or 10% (n=5). Small mural thrombi composed of aggregated platelets were produced, but no occlusive thrombi developed in any flow reduction. Three weeks after the first balloon injury, neointima with tissue factor expression and increased procoagulant activity was developed. Balloon injury of the neointima with the same blood flow reduction (n=5) induced fibrin-rich thrombus formation. Additionally, injury with flow reduced to 25% and 10% promoted thrombus propagation resulting in vessel occlusion within 160+/-18 and 71+/-17 seconds, respectively. An injection of anti-von Willebrand factor (vWF) monoclonal antibody (AJW200; 1.0 mg/kg) prevented occlusive thrombus formation.

CONCLUSIONS

Increased vascular wall thrombogenicity together with a substantial blood flow reduction is crucial for occlusive thrombus formation, and vWF plays an important role in thrombus propagation. Reduced blood flow at plaque disruption sites might contribute to thrombus propagation leading to acute coronary syndromes.

Atheroembolic renal disease: clinical findings of 11 cases

Atheromatous embolism is a systemic disease resulting from cholesterol crystal embolization in many organs, including the kidneys. To characterize atheroembolic renal disease (AERD), we retrospectively evaluated 11 patients with acute renal failure after vascular surgery, vascular radiology investigations, and anticoagulation at Miyazaki Medical College from 1994 to 2001. The diagnosis of cholesterol atheromatous embolism was confirmed by tissue examination or clinical grounds. The patients were all elderly men (average age of 66.8 years) with a history of hypertension (55%), diabetes mellitus (45%), hyperlipidemia (45%), and coronary artery disease (18%). Seven patients had livedo reticularis, and 4 had blood eosinophilia. Clinically, 7 patients were managed conservatively and 5 of them improved, whereas 4 patients required dialysis and developed chronic renal failure or died. The serum creatinine levels of the improved patients were significantly lower (1.28+/-0.3 mg/dl, p < 0.005) than the non-improved ones (7.70+/-3.6). The number of eosinophils was significantly higher in the improved patients (576+/-295 /ml, p < 0.05) than in the non-improved ones (208+/-206). However, no significant difference was observed in the levels of serum cholesterol and C-reactive protein among these patients. Since the population at risk for AERD is growing, we should recognize this disease as a cause of acute renal failure.

Contribution of von Willebrand factor to thrombus formation on neointima of rabbit stenotic iliac artery under high blood-flow velocity

OBJECTIVE

It has become clear that von Willebrand factor (vWF) plays important roles in platelet adhesion and aggregation under high blood-flow velocity conditions observed in stenotic atherosclerotic arteries. However, its roles in thrombus formation in vivo on diseased arteries have not been fully understood. We examined the contribution of vWF to thrombus formation and subsequent intimal growth by using a repeated balloon-injury model in rabbits.

METHODS AND RESULTS

Rabbit iliac arteries 4 weeks after a first balloon injury showed 37% luminal stenosis by neointimal growth, and blood velocity increased by 2.1 times compared with that of uninjured arteries. The second balloon injury induced fibrin-rich thrombus formation on the injured neointima. Intravenous administration of a monoclonal antibody against vWF (AJW200, 1.0 mg/kg body weight) remarkably prevented botrocetin-induced platelet aggregation ex vivo for 2 days; moreover, thrombus formation, cell proliferation, and subsequent neointimal growth were significantly reduced at 30 minutes, 5 days, and 4 weeks, respectively, after the second balloon injury.

CONCLUSIONS

These results indicate that vWF plays a potent role in fibrin-rich thrombus formation on the neointima under high blood-flow velocity conditions. Inhibition of plasma vWF activity might be effective for the reduction of thrombus formation and/or subsequent neointimal development after coronary interventions.

Immunohistological localization and possible functions of adrenomedullin

In this short review, we describe the distribution of adrenomedullin (AM)-immunoreactive cells in human tissues and their related biological properties, focusing on the blood coagulation and mucosal defense systems. AM is widely distributed in human tissues, especially in cardiovascular and endocrine tissues. Within vessels, AM has been immunohistochemically detected in vascular smooth muscle cells (SMCs) and endothelial cells (ECs). In atherosclerotic lesions, the peptide is present not only in these cells, but also in macrophages, and the most intense AM immunoreactivity is detected in macrophages located in shoulder lesions of atheromatous plaque, which are considered to be rupture-prone regions. AM inhibits tissue factor production, and augments the production and release of tissue factor pathway inhibitor from aortic ECs. AM also induces the release of antithrombin and urokinase-type plasminogen activator from ECs. Taken together, these antithrombotic properties of the peptide are expected to play an important role in the maintenance of blood circulation. Furthermore, AM immunoreactivity is observed in mucosal and glandular epithelia of the gastrointestinal, respiratory and reproductive systems. AM and the proadrenomedullin N-terminal 20 peptide (PAMP) show strong antibacterial activity against Escherichia coli. In addition, AM is also present in the auditory system. These lines of evidence suggest that AM and its related peptides not only play a role in vasodilatation, but also exhibit multiple biological activities in mammals.

Adrenomedullin augments the release and production of tissue factor pathway inhibitor in human aortic endothelial cells

OBJECTIVES

Adrenomedullin (AM) is a hypotensive and vasodilative peptide. It has been reported that AM plays several biological roles in cardiovascular and endocrine systems, however, effects on the blood coagulation system have not been examined. In this study, we examined its effect on tissue factor pathway inhibitor (TFPI), which is a potent inhibitor of tissue factor/factor VIIa complex-induced coagulation cascade, and is synthesized and constitutively secreted by endothelial cells (ECs). The aim of this study was to elucidate the effects of AM on release and production of TFPI in ECs.

METHODS

Cultured human aortic ECs were incubated with AM (10(-14)-10(-6) M), and the antigen levels and activity of the free and total form of TFPI after AM exposure were measured in culture media using ELISA. Furthermore, receptor interaction and cellular signaling of AM were investigated.

RESULTS

AM augmented TFPI release and production in a dose-dependent manner. The effect on TFPI production was inhibited by AM receptor antagonist (AM22-52), the monoclonal antibody against C-terminal region of AM, MAPKK inhibitor, and cAMP antagonist.

CONCLUSION

These findings indicate that AM might play an important role in the modulation of anticoagulant properties in blood circulation.

Protease-activated receptor 2 (PAR2) mediates vascular smooth muscle cell migration induced by tissue factor/factor VIIa complex

Protease-activated receptor 2 (PAR2) is one of G-protein-coupled receptors able to be activated by trypsin and coagulation factor VIIa. We previously reported that tissue factor/factor VIIa (TF/FVIIa) complex was a strong chemotactic factor for cultured vascular smooth muscle cells (SMCs). The migratory response was dependent on a catalytic activity of FVIIa, and did not involve factor Xa and thrombin generation. In this study, we examined TF/FVIIa-induced SMC migration.

METHODS

The contribution of PAR2 to TF/FVIIa-induced vascular SMC migration was investigated using a modified Boyden's chamber method, and the distribution of PARs in the human coronary arteries and cultured SMCs was also examined.

RESULTS

Trypsin and PAR2-activating peptide (AP; SLIGKV) stimulated SMC migration in a dose-dependent manner, of which abilities were comparable to those of TF/FVIIa complex and platelet-derived growth factor-BB, but PAR1-AP (TFLLR or SFLLR) or PAR4-AP (AYPGOV) did not elicit the migration. The antisera against PAR2-AP significantly inhibited TF/FVIIa-induced SMC migration, but that of PAR1-AP did not. In immunostaining, both intimal SMCs of the human coronary arteries and cultured SMCs showed positive reaction for PAR2-AP.

CONCLUSION

These results suggest that PAR2 in SMCs plays a crucial role in the cell migration induced by TF/FVIIa complex.

Intravascular ultrasound imaging in the assessment of atherosclerotic plaques in rabbit abdominal aorta: comparison with histologic findings

RATIONALE AND OBJECTIVES

To examine the correlation between the echogenicity and the components of atherosclerotic plaques in rabbit.

METHODS

The atherosclerotic plaque formation in the abdominal aortas of hyperlipidemic or normolipidemic rabbits was stimulated by inserting polyethylene tubing. Intravascular ultrasound (30-MHz, 4.5 F catheter) investigation was performed at locations in the vessel. The intravascular ultrasound images of the plaques were evaluated and compared with the histologic findings.

RESULTS

Ultrasound images delineated areas showing hyperechoic or hypoechoic ultrasound beams in the plaques. Histologic studies revealed that the hyperechoic areas were closely associated with a dense fibrous extracellular matrix, whereas the hypoechoic areas corresponded to lesions showing a marked accumulation of foamy macrophages or proteoglycan-rich loose myxoid extracellular matrix with smooth muscle cell proliferation.

CONCLUSION

A good correlation between ultrasound images and histologic features was observed. These results suggest that intravascular ultrasound imaging could provide useful information for assessing the tissue characteristics of atherosclerotic lesions.

Adrenomedullin and proadrenomudullin N-terminal 20 peptide (PAMP) are present in human colonic epithelia and exert an antimicrobial effect

The hypotensive and vasorelaxing peptides adrenomedullin (AM) and its gene-related peptide, proadrenomedullin N-terminal 20 peptide (PAMP), were found to be distributed on the surface of the colonic mucosa. AM and PAMP showed dose-dependent antimicrobial activity against E. coli. The results suggest that the novel vasoactive peptides AM and PAMP play an important role in mucosal defence.

Biosynthesis and secretion of adrenomedullin and proadrenomedullin N-terminal 20 peptide in a rat model of endotoxin shock

To study the biosyntheses and pathophysiological roles of adrenomedullin (AM) and proadrenomedullin N-terminal 20 peptide (PAMP) in septic shock, we compared the time course of plasma concentrations of these peptides and blood pressure in rats injected with either 0.9% saline (control group) or lipopolysaccharide (LPS group). The plasma AM concentration in the LPS group did not increase 30 and 60 min after LPS injection, at which time points the blood pressure remained low. Thereafter, AM rapidly increased, and it amounted to 35 times the basal value 4 h after injection, when the blood pressure returned to the basal level. The increment of plasma PAMP in the LPS group was lower than that of AM. We also examined the tissue concentration of AM and PAMP--as well as the tissue expression of proadrenomedullin (proAM) mRNA--in the LPS and control groups. LPS significantly increased the tissue concentrations of AM and PAMP in the lung, but decreased them in the adrenal gland and cardiac atrium. The LPS injection augmented proAM gene transcription in the lung, adrenal gland and aorta. In an immunohistochemical examination, AM staining was intense in alveolar endothelial cells of the lung in the LPS group. Thus, this septic shock model had high plasma levels of PAMP as well as AM, while the biosynthesis and secretion of the two peptides may have been differentially regulated in various tissues of rats injected with LPS. The present results suggest that these two bioactive peptides may play different roles in the pathophysiology of septic shock.

Second nation-wide study of atherosclerosis in infants, children and young adults in Japan

This paper reports the results of the second nation-wide cooperative study of atherosclerosis in young Japanese, aged from 1 month to 39 years, who were autopsied between 1991 and 1995. Atherosclerotic lesions in 1066 aortas and 974 coronary arteries were classified into fatty streaks, fibrous plaques and complicated lesions and quantificated with the point-counting method. The results of this study were compared with those of the former study, which was conducted 13 years earlier in almost the same fashion as this study. Atherosclerosis of aorta, which was determined by surface involvement (SI) of atherosclerotic lesions and atherosclerotic index (AI), increased with age in both sexes of the former and the present studies and their tendency for the progression of the extent of atherosclerotic lesions appeared to be similar. In the coronary arteries, the mean values of SI and AI in the males of the present study were greater significantly than those in the male of the former studies and in the female of the both studies in the third and fourth decades. This difference suggests that atherosclerotic lesions are increasing in young Japanese males. It also suggests that these subjects may be increasingly susceptible to atherosclerotic cardiovascular disease with increasing age.

Coronary atherosclerosis in youths in Kyushu Island, Japan: histological findings and stenosis

We histologically examined the coronary arteries of 52 autopsied cases of the youths (3 to 39 years of age, mean 28.5 years) in Kyushu island, Japan, without clinical events of coronary artery diseases. The coronary artery specimens were taken from the proximal portions of the right coronary artery (Seg. 1), the left anterior descending artery (Seg. 6), and the macroscopically most stenotic region (ST). Atherosclerotic lesions were histologically classified into four types: concentric fibrous, eccentric fibrous, concentric lipid rich, or eccentric lipid-rich type. The degrees of stenosis (< 25%, 25-50%, 50 75%, > 75%) were morphometrically evaluated. The majority of coronary arteries with under 50% stenosis were of the concentric fibrous type. Lipid-rich types of coronary atherosclerosis increased in the coronary arteries with over 50% stenosis and were observed in the Seg. 6 and ST, while 70% of Seg. 1 lesions with over 50% stenosis were of a fibrous type. Serum cholesterol levels of patients with a lipid rich type of coronary atherosclerosis were significantly higher than those with a fibrous type. These results suggested that the early stage of coronary atherosclerosis in Japanese youths is mainly of a concentric fibrous type, which later develops to a lipid rich type. Hypercholesterolemia would promote the progression of atherosclerosis.

Field evaluation of who hemoglobin color scale in West Java

The results obtained with a WHO hemoglobin (Hb) colour scale were evaluated in a field study in Chibubur district in Java island by comparison with hemoglobin values obtained by an automated blood cell analyzer K-800 (Sysmex. Kobe, Japan). When the color scale test was performed following the instructions for use. Hb values observed were usually higher than the values obtained by the analyzer. Thirty microl blood was loaded on the filter paper and an 60 sec waiting period was used. The sensitivity of results obtained with the color scale was 23.3% (14/60), and specificity was 96.6% (58/60). We propose an additional testing method based on our results.

Country reports from Japan: external quality assessment scheme in Japan

Several external quality assessment schemes (EQAS) have been conducted in Japan. Results obtained from nation-scale EQAS reveal the current quality of laboratory testing in each laboratory. The largest nation-scale EQAS in Japan is that conducted by the Japan Medical Association. The numbers of participants and of items evaluated have increased in EQAS by JMA over its history of 32 years. Improvement in inter-laboratory differences has been observed for most items in EQAS in recent decades. In 1998, about 2,500 laboratories from throughout the country participated in this surveillance, and 47 items were evaluated. The coefficient of variations for the group of all participants was less than 5% for about one third of all test items. On the other hand, very high variations over 20% were observed for 6 items. Also, inter-method differences exist for many items, which may be or may not be related to matrix effects. Retrospective evaluation of all EQAS data suggests that there is still room for improvement in inter-laboratory differences.

Novel distribution of adrenomedullin-immunoreactive cells in human tissues

Adrenomedullin (AM) is a novel hypotensive and vasodilator peptide. We previously examined the localization of AM in human, rat, and porcine tissues using a polyclonal antibody against synthetic human AM[40-52]. We demonstrated that AM is widely distributed in the endocrine and neuroendocrine systems, but not in the heart, kidney, or blood vessels, although high levels of AM mRNA were detected in the latter tissues. In this study, we further investigated the distribution of AM by using two newly developed monoclonal antibodies against synthetic human AM peptides, [12-25] and [46-52]. AM immunoreactivity was observed in cardiac myocytes, vascular smooth muscle cells, endothelial cells, and renal distal and collecting tubules. In addition, AM-immunoreactive (IR) cells were found in mucosal and glandular epithelia of the digestive, respiratory, and reproductive systems, as well as the endocrine and neuroendocrine systems. These findings indicate that AM-IR cells are more widely distributed in human tissues and suggest that AM might play multiple biological roles in humans.

[Histopathology of thrombotic vascular diseases]

Three principal factors predispose to thrombus formation (Virchow's triad): (1) endothelial injury, (2) stasis or turbulence of blood flow, and (3) blood hypercoagulability. Endothelial denudation is the most important factor, especially in the development of arterial thrombus. Arterial thrombi are frequently occlusive, and the most common sites are coronary, cerebral, and femoral arteries. The thrombi induce severe ischemia or infarction of the heart, brain, and lower extremities. The thrombi are usually superimposed on an atherosclerotic plaque. Plaque rupture or erosion is considered to be the trigger of acute thrombus formation. While venous thrombi are invariably occlusive, and commonly affect the lower extremities. Static blood flow, phlebitis, and genetic and acquired hypercoagulability often contribute to venous thrombosis.

Cross over placebo control trial of dilazep in beta-thalassemia/hemoglobin E patients

An attempt was made to find better symptomatic treatment for beta-thalassemia/hemoglobin E (beta-thal/Hb E) patients in order to reduce their blood demand. Oral administration of dilazep was prescribed for these patients and a clinical trial was conducted over a 2-year period as a cross over placebo control study. Seventeen beta-thal/Hb E patients were enrolled in the study. All of them received dilazep and placebo for 10 months at different periods of time and were taken care of by the same doctor throughout the study. The blood demand of the same patients during the period of receiving dilazep with the period of receiving placebo, was 1.5 +/- 1.8 U/10 months versus 2.2 +/- 2.6 U/10 months, respectively. Thus dilazep showed a benefit in decreasing the blood demand by about 50% although the results did not reach statistical significance (p = 0.1). There was a statistical difference in hemoglobin concentration of the patients receiving dilazep compared with placebo (p = 0.038). While receiving dilazep the mean +/- SD hemoglobin level was 5.82 +/- 0.8 g/dl, significantly higher than while receiving placebo (5.66 +/- 0.9 g/dl) (p = 0.038). The liver, and renal function tests, and cardiac enzyme levels of the patients showed no significant changes throughout the study. However, one case had a problem with bleeding following tooth extraction whilst receiving dilazep and needed 1 unit of blood transfusion. In conclusion, administration of dilazep to patients with beta-thal/Hb E increased the patients' hemoglobin and reduced their blood demand with few side effects.

Cell density of adrenomedullin-immunoreactive cells in the gastric endocrine cells decreases in antral atrophic gastritis

AIMS

Adrenomedullin (AM) is a novel hypotensive and vasorelaxing peptide recently isolated from human phaeochromocytoma tissue, and is widely distributed in various organs. In this study we examined the localization of AM-immunoreactive (IR) cells in the gastric mucosa and AM-IR cell density in antral atrophic gastritis.

METHODS AND RESULTS

Gastric mucosal tissues were taken from the gastric body and antral mucosa of 52 patients (27 men, 25 women; mean age 56.0 (range 20-86) years). Immunohistochemical analysis revealed that AM-IR cells were present in the pyloric glands, but not in the fundic glands, and that AM-IR cells were stained positively for chromogranin A and gastrin. The percentage of AM-IR cells vs chromogranin A- and gastrin-IR cells was 42 and 56%, respectively. The number of AM-IR cells decreased with the progression of severity of atrophic changes in the pyloric gland, and also of mononuclear cell infiltration. There was no correlation between the number of AM-IR cells and the degree of neutrophilic infiltration. Similar findings were also obtained for gastrin-IR cells.

CONCLUSION

AM-IR cells are present in the endocrine cells including gastrin-IR cells in the pyloric glands. These results suggest that AM may contribute to gastrin secretion in the pyloric glands.

Hepatic stellate cells (Ito cells) in veno-occlusive disease of the liver after allogeneic bone marrow transplantation

AIMS

To evaluate the role of activated hepatic stellate cells (HSCs) in hepatic veno-occlusive disease (VOD) after bone marrow transcription (BMT), we studied the distribution and area of activated HSCs by immunohistochemistry for alpha-smooth muscle actin (SMA).

METHODS AND RESULTS

We examined the liver of seven autopsy cases with hepatic VOD or without VOD after allogeneic BMT and five autopsy cases without liver disease as a control both microscopically and immunohistochemically. In normal liver tissues, SMA-positive cells were observed around the central veins, while they were more frequently noted along the sinusoidal walls as well as around the central veins in liver tissues with or without VOD after BMT. The area of activated HSCs increased significantly in zones 1 and 2, and more prominently in zone 3 of the liver tissues after BMT than normal liver tissues, and was much larger in zone 3 of liver tissues with VOD. The activated HSCs were immunohistochemically negative for the regulatory contractile proteins (heavy caldesmon and calponin).

CONCLUSIONS

These results indicated that the activated HSCs may play an important role in sinusoidal fibrosis and luminal narrowing or occlusion of the central veins in VOD after BMT.

Adrenomedullin in the gastrointestinal tract. Distribution and gene expression in rat and augmented gastric adrenomedullin after fasting

The aim of this study was to investigate the regional distribution, molecular forms, and gene expression of adrenomedullin in the rat gastrointestinal tract and to examine physiological changes in gastric adrenomedullin after 24-h fasting. The tissue concentration was measured by radioimmunoassay. The molecular forms were analyzed by high performance liquid chromatography. mRNA levels were quantified by Northern blotting and cells positive for adrenomedullin immunoreactivity were localized by immunohistochemistry. A high concentration of adrenomedullin was found in stomach, cecum, and colon (450-520 fmol/g wet tissue). Adrenomedullin immunoreactivity was also detected in duodenum, jejunum, and ileum (200-250 fmol/g wet tissue). Transcripts of the adrenomedullin gene were widely expressed throughout the gastrointestinal tract. The major form of adrenomedullin immunoreactivity in stomach and colon corresponded precisely with authentic adrenomedullin peptide. Adrenomedullin immunoreactive cells were present in the gastrointestinal endocrine system. The concentration and mRNA level of gastric adrenomedullin after fasting were significantly increased compared with findings in controls. Adrenomedullin is ubiquitous in the gastrointestinal tract, and may be produced by endocrine cells. The results suggest that adrenomedullin, through its potent vasodilating activity, may play some role, in the stomach including the regulation of the mucosal blood flow.

The role of tissue factor in the pathogenesis of thrombosis and atherosclerosis

TF is a major regulator of coagulation and hemostasis. High levels of TF antigen and activity are detected in atherosclerotic lesions, particularly in the advanced lesions. When the plaques are ruptured or eroded, exposure of cellular and extracellular TF to circulating blood play a pivotal role in mediating fibrin-rich thrombus formation leading to acute coronary syndromes. On the other hand, activation of blood coagulation and deficiency of coagulation inhibitors, without endothelial cell denudation, are considered to be an important factor of thrombogenesis in the microcirculation. The imbalance between TF and TFPI seems to be important in promoting fibrin thrombus formation in the lung of endotoxin induced DIC condition.

Fibrin-rich and platelet-rich thrombus formation on neointima: recombinant tissue factor pathway inhibitor prevents fibrin formation and neointimal development following repeated balloon injury of rabbit aorta

Thrombus formation and neointimal growth are the critical events in restenosis after balloon angioplasty. However, the responses of diseased vessels to injuries caused by balloon angioplasty have not been well examined. We investigated the thrombus formation and neointimal development following the balloon injury to the previously induced neointima in the rabbit aorta and the effects of recombinant tissue factor pathway inhibitor (rTFPI) on these responses. Rabbit thoracic aortas were subjected to injury with a Fogarty 4F balloon catheter at 1.75 atm (first injury), and 4 weeks later the same vessels were subjected to the second injury with a Swan-Ganz 5F balloon catheter at 1.4 atm (mild-injury group) or 1.8 atm (severe-injury group), and immediately after that a retrograde bolus injection of rTFPI (100 microg/kg body weight) or saline was performed into the injured segments via the central tube of the Swan-Ganz catheter. Twenty minutes after the second injury, the injured surfaces were covered with platelet-rich thrombi in the mild-injury group and with fibrin-rich thrombi in the severe-injury group. Damaged intimal smooth muscle cells, which were immunohistochemically positive for tissue factor (TF), were observed beneath the fibrin-rich thrombi. The neointima 4 weeks after the second injury was significantly thicker in the severe-injury group than in the mild-injury group. The bolus infusion of rTFPI markedly inhibited fibrin formation on the injured surfaces, and significantly reduced the neointimal development in the severe-injury group at 4 weeks after the second injury. These results indicate that TF-dependent coagulation pathway is primarily responsible for fibrin-rich thrombus formation and may play an important role in neointimal development following the balloon injury to the rabbit aortic neointima. Additionally the bolus administration of rTFPI to the injured vessels could prevent mural thrombus formation and neointimal growth after balloon angioplasty.

Expression of tissue factor in the rabbit aorta after balloon injury

Tissue factor (TF) is a primary initiator of the extrinsic pathway of blood coagulation. Recently TF has been shown to be overexpressed in atherosclerotic lesions and it is thought to contribute to the thrombogenicity of the plaques. We studied TF expression in the media and the neointima of rabbit aortas at various intervals after balloon injury. TF protein was immunohistochemically detected in smooth muscle cells (SMCs) of the inner layer of the media at 2 h after injury and was subsequently detected in SMCs in the neointima, whereas no TF expression was detected in the uninjured aortas except for the adventitia. Immunohistochemical and immunoelectron microscopic studies revealed that TF-positive SMCs were of an immature or synthetic phenotype and TF protein was detected in the rough endoplasmic reticulum in SMCs. TF mRNA in the intima and media increased at 2 h after injury and returned to near baseline levels at 12-24 h, whereas TF activity also increased at 2 h and continued at similar levels over the next 72 h. TF mRNA and activity increased markedly at 2-8 weeks after injury. These data suggest that TF is rapidly induced in the medial SMCs and hereafter is constitutively expressed in the neointima. TF expressed in the neointima may contribute to hypercoagulable properties of injured arteries.

Malignant mesothelioma of the pleura with a large tumor embolus in the left atrium: an autopsy case

Malignant mesothelioma of the pleura often involves the heart but seldom invades the intracardiac cavity. We report a 78-year-old woman with right pleural mesothelioma who died of heart failure. An autopsy revealed that the tumor was present at the right pleura and invaded the right upper lobe of the lung and the mediastinum. The tumor also extended to the left atrium via the right pulmonary vein and filled the atrial cavity. Repeated transthoracic echocardiography failed to detect the tumor, but magnetic resonance imaging was useful for diagnosis.

A double-blind placebo control trial of dilazep in beta-thalassemia/hemoglobin E patients

Since the obtained results from the pilot study indicated that dilazep which was a membrane stabilizer would be benefit to treatment and prevention of anemia and chronic leg ulcer in beta-thalassemia/hemoglobin E (beta-thal/HbE) patients, the authors had continued the study in a second phase, ie a double blind placebo control trial. Twenty-seven beta-thal/HbE patients were recruited in the study. Eight patients who suffered from chronic leg ulcer were given dilazep. The rest of patients were given dilazep or placebo according to a randomized table. Hence, 16 patients received dilazep and 11 received placebo. When we compared the number of unit of blood transfusion, hemoglobin level, 2-3 DPG and P50 value between the dilazep and placebo groups using unpaired t-test, we found that there were no statistical differences in any of the parameters. However, when we compared the data within the group using paired t-test, there was statistical decrease in blood requirement after treatment in the dilazep group (p < 0.05). Concerning with the treatment of chronic leg ulcer, 3 in 8 patients were completely healed within 3 months, 4 in 8 patients were improved and 1 in 8 patients was not improved. There were complaints of skin itching and mild epigastric pain in placebo group but the liver function tests, kidney function tests and cardiac enzyme did not significantly change during the medication.

Pulmonary microthromboembolism by injection of sonicated autologous blood in rabbits with splenic artery ligations

Chronic pulmonary thromboembolism (PTE) has been reported to play an important role in cardiac failure in thalassemic patients after splenectomy. However, the mechanism of PTE in these patients remains unclear. In this study, we attempted to establish an animal model of PTE seen in thalassemic patients after splenectomy. We divided New Zealand white rabbits into three groups: Group 1 was injected sonicated blood, II was injected non-sonicated blood after ligation of the splenic artery, and III was injected sonicated blood after ligation of the splenic artery. After injection of the sonicated blood, we counted the platelet number until 1 hour and the rabbits were sacrificed for histological examination. Platelets significantly decreased in number immediately after injection of the sonicated blood in Groups I and III. Many pulmonary thromboemboli composed mainly of platelets were found in Group III but not in other groups. These pathological changes seem to be partly similar to those of thalassemic patients after splenectomy. This animal model is thought to be useful to study the pathogenesis of pulmonary thromboembolism, especially in thalassemic patients after splenectomy.

[The significance of the cerebellar tonsillar herniation on the cause of sudden death of ruptured cerebral aneurysm]

We experienced a case with sudden unexpected death caused by rupture of an intracranial aneurysm, which was confirmed by autopsy. Depending on this case, we reported the significance of the cerebellar tonsillar herniation on the cause of sudden death of ruptured cerebral aneurysm. A 58-year-old man was admitted to us for treatment of subarachnoid hemorrhage (SAH). The CT scanning showed diffuse SAH in the whole cistern. Cerebral angiography on admission revealed an aneurysm at the bifurcation of the left middle cerebral artery in association with bleb like configuration. The aneurysmal neck was clipped on the day of admission. The postoperative course was uneventful. In the early morning of postoperative 23rd day, he was found being expired. To clarify the cause of death, an autopsy was done, disclosing diffuse SAH in association with tonsillar herniation more marked on the left. Thus, the distortion of the spinomedullary junction due to asymmetrical herniation was considered to be responsible for unexpected sudden death in this case. Examination of the major cerebral artery disclosed a ruptured anterior communicating artery aneurysm.

An isolated case of nephronophthisis: medullary cystic disease without typical onset

A 16-year-old girl with renal failure was transferred to our hospital for an extensive renal examination. Computerized tomography and ultrasonography showed multiple small cysts throughout the medulla of both kidneys. Histological findings revealed tubular atrophy and dilatation and marked periglomerular fibrosis, all of which were compatible with nephronophthisis. Her development and growth were normal. A prior urinalysis, as well as her symptoms and family history were not helpful for making a diagnosis. As early diagnosis of nephronophthisis is difficult in some cases, more detailed screening is needed for children and adolescents.

Expression of tissue factor and tissue factor pathway inhibitor in rats lungs with lipopolysaccharide-induced disseminated intravascular coagulation

Disseminated intravascular coagulation (DIC) is a frequent complication of endotoxin shock, and modulation of endothelial cell hemostatic properties has been proposed to play an important role in its onset. We examined the in vivo expression of tissue factor (TF) and TF pathway inhibitor (TFPI) in rat lungs of a lipopolysaccharide (LPS)-induced DIC model. Light and electron microscopic studies showed that fibrin-rich thrombi were present in the pulmonary microvasculature 3 hours after intraperitoneal injection of LPS (7.5 mg/kg) and increased in number at 6 hours. In an immunohistochemical study, an increase in number of monocytes in the microvasculature was observed after LPS injection, and many of these cells (> 90%) were positive for TF antigen. However, no TF expression in endothelial cells was detected. Pulmonary endothelial cells showed positive reaction for TFPI antigen before LPS injection, but TFPI-positive endothelial cells markedly decreased in number after LPS injection. mRNA expression of TF increased and that of TFPI decreased in the lung tissue 3 and 6 hours after LPS injection. High values of TF activity were detected in the lung tissue and plasma, whereas TFPI activities decreased after LPS injection. These results indicate that imbalance between TF and TFPI, overexpression of TF, and underexpression of TFPI in the lung may contribute to thrombus formation in this LPS-induced DIC model.

Analysis of tissue factor and tissue factor pathway inhibitor expression in human colorectal carcinoma cell lines and metastatic sublines to the liver

To investigate the expression of tissue factor (TF) and tissue factor pathway inhibitor (TFPI) in human colorectal carcinomas, Northern blot analysis was performed in a series of human colorectal carcinoma cell lines and in normal or tumoral colorectal tissues. Of 16 human colorectal carcinoma cell lines examined, most expressed TF mRNA, though the levels of expression varied significantly. Considerably higher expression was observed in the cell line CaR-1, while lines established from metastatic lesions tended to express abundant TF mRNA. By contrast, TFPI mRNA levels were low in these high TF-expressing cell lines. TFPI was expressed abundantly in WiDr and in a few other cell lines which expressed a very low level of TF mRNA. Immunocytochemically, both proteins were stained predominantly on the cell surface; however, diffuse cytoplasmic staining for TF also was observed in CaR-1 cells. In addition, the cell surface TF activity was significantly higher in CaR-1 cells than in WiDr cells, confirming the results of mRNA analysis. The level of TF mRNA in colorectal carcinoma tissue in vivo and its ratio to the normal counterpart also varied significantly among the cases. To search for a possible role of TF/TFPI in metastasis of colorectal carcinoma cells, the expression of these genes was compared between a rectal adenocarcinoma cell line, RCM-1, and its highly metastatic subline, RCM-1 L-10. Compared with the parent line, RCM-1 L-10 expressed 7.5-fold higher levels of TF mRNA, whereas TFPI expression was not altered significantly or even decreased slightly. The higher cellular TF activity was confirmed in the metastatic subline in comparison with the parent line.

Localization and activity of tissue factor in human aortic atherosclerotic lesions

Tissue factor (TF) is a transmembrane protein that serves as the major initiator of the blood coagulation cascade. The overexpression of TF antigen and mRNA has previously been reported in advanced atherosclerotic lesions. Recently TF procoagulant activity has also been identified in these lesions. However, localization and activity of TF in various stages of atherosclerosis have not yet been reported. We studied TF localization and its activity in three stages of the human atherosclerotic lesions (diffuse intimal thickening, fatty streak, and atheromatous plaque). The thoracic aortas were obtained from 23 autopsy cases and were examined immunohistochemically using an anti-human TF polyclonal antibody and biotinylated factor VIIa (FVIIa) as a probe to test the FVIIa-binding ability of TF. In addition, the TF-mediated activation of factor X (FX) was quantitatively assessed using a chromogenic assay. In lesions of the diffuse intimal thickening and the fatty streak, almost all of intimal smooth muscle cells (SMCs), macrophages, and endothelial cells were positive for TF. In the atheromatous plaques, TF antigen was detected extensively in the extracellular matrix as well as in the intimal cells. TF in all stages of atherosclerotic lesions had the ability to bind biotinylated FVIIa. TF activity was detected in each lesion and was more prominent in fatty streaks and atheromatous plaques than in the diffuse intimal thickening. These results indicate that active TF is expressed in the early stage of atherosclerotic lesions as well as in the advanced stage, and it contributes to the thrombotic property of human atherosclerotic lesions.

Tissue factor pathway inhibitor inhibits aortic smooth muscle cell migration induced by tissue factor/factor VIIa complex

Tissue factor (TF), a transmembrane glycoprotein, forms a high affinity complex with factor VII/VIIa (FVIIa) and thereby initiates blood coagulation. Tissue factor pathway inhibitor (TFPI) is an endogenous protease inhibitor of TF/FVIIa-initiated coagulation. We previously reported that TF was a strong chemotactic factor for cultured vascular smooth muscle cells (SMCs). In this study, we examined the contribution of FVIIa and the effect of TFPI to TF-induced cultured SMC migration. TF/FVIIa complex showed a strong migration ability, however, neither TF alone nor FVIIa induced SMC migration. TF/FVIIa treated by a serine protease inhibitor and the complex of TF and inactivated FVIIa (DEGR-FVIIa) did not stimulate SMC migration. Pretreatment with hirudin and the antibodies to alpha-thrombin and factor X had no effect on TF/FVIIa-induced SMC migration, although alpha-thrombin and factor Xa also induced SMC migration respectively. TFPI markedly inhibited TF/FVIIa-induced SMC migration in a concentration-dependent manner, but did not affect the SMC migration induced by platelet-derived growth factor (PDGF)-BB, basic fibroblast-growth factor (bFGF), or alpha-thrombin. These results indicate that the catalytic activity of TF/FVIIa complex is important on SMC migration, and TFPI can reduce SMC migration as well as thrombosis.

Intravenous injection of sonicated blood induces pulmonary microthromboembolism in rabbits with ligation of the splenic artery

Pulmonary thromboembolism (PTE) is found in long hospitalized patients. Chronic PTE has been reported to play an important role in cardiac failure in thalassemic patients after splenectomy. However, the mechanism of PTE in these patients remains unclear. In this study, we attempted to establish an animal model of PTE. We divided New Zealand white rabbits into three groups: Group I was injected sonicated blood, II was injected non-sonicated blood after ligation of the splenic artery, and III was injected sonicated blood after ligation of the splenic artery. After injection of the sonicated blood, we examined the platelet counts every 10 minutes until 1 hour and the rabbits were sacrificed for histological examination. Platelets significantly decreased in number immediately after the injection of sonicated blood in Groups I and III. Many pulmonary thromboemboli composed mainly of platelets were found in Group III but not in other groups. These pathological changes seem to be partly similar to those of thalassemic patients after splenectomy. This animal model is thought to be useful to study the pathogenesis of pulmonary thromboembolism, especially in thalassemic patients after splenectomy.

Modulation of E-cadherin expression in TPA-induced cell motility: well-differentiated human adenocarcinoma cells move as coherent sheets associated with phosphorylation of E-cadherin-catenin complex

We previously presented a two-dimensional cell motility assay using L-10, a highly metastatic variant of the human rectal adenocarcinoma cell line RCM-1, as a motility model of tumor cells of epithelial origin. In this model, L-10 cells moved outward from the cell islands mainly as a localized coherent sheet of cells when stimulated with 12-O-tetradecanoylphorbol-13-acetate (TPA). Electronmicroscopic study of the migrating cell sheets revealed that wide intercellular gaps had developed at the lower portion of the cells, allowing them to extend leading lamellae, whereas close cell-cell contacts remained at the upper portion of the cells. In the present study, the mechanism involved in this localized modulation of cell-cell adhesion at the lower portion of the cells was investigated with special reference to E-cadherin expression. E-cadherin immunostaining, which was demonstrated using an anti-E-cadherin mAb, HECD-1, was decreased in migrating L-10 cell sheets. Apparently, however, E-cadherin was involved in the sheet formation of migrating cells because simultaneous or sequential treatment with TPA and HECD-1 inhibited sheet formation and caused scattering of migrating cells. With immunoelectron microscopic study, E-cadherin immunoreactivity was confined to the upper portion of migrating cells and lost at the lower portion. The level of E-cadherin and alpha-catenin expression was not altered by TPA treatment, although tyrosine phosphorylation of E-cadherin and catenins increased 1.6- to 1.9-fold. We propose that cells are released from cell-cell adhesion only at the lower portion of the cells via phosphorylation of the E-cadherin-catenin complex when stimulated with TPA. This change allows the cells to extend leading lamella and thus move together as coherent sheets (cohort migration).