Can health systems be enhanced for optimal health services through disease-specific programs? Results of field studies in Viet Nam and Cambodia

Developing better health systems is the key to delivering optimal health services, although more evidence of effective strategies to do so is needed. Field surveys were conducted in Viet Nam and Cambodia to identify best practices in addressing health system bottlenecks to scale up disease control programs. The two countries were compared over time using a framework for analysis developed by the authors. In Viet Nam, a health system was in place for decades at the central to municipal levels, although it was fragile until the 1990s, when the government started taking measures. In Cambodia, the previous health system had been destroyed during previous internal conflict. In the post-conflict period, the health system was rebuilt with support for programs followed by centralization of health services. In different settings, different measures were taken to deal with similar bottlenecks. In Cambodia, vertical programs were dominant, so the government sought to centralize drug management to deal with shortages of essential drugs, while Viet Nam sought to mobilize resources to ensure drug distribution at all levels. This study shows there is no single successful approach to health systems, and a systemic approach needs to be taken because elimination of one bottleneck may reveal another. Efforts to enhance disease-specific programs may not always contribute to overall enhancement of the health system, and the best possible approach may not be the same in different countries. Further study is needed to explore common issues and principles for effective strategies to enhance health systems in different contexts.

Thoracic endovascular aortic repair for aortic complications after esophagectomy for cancer: report of three cases

Aortic complications after esophageal cancer surgery are rare and usually fatal. Here, we report three patients who underwent thoracic endovascular aortic repair (TEVAR) for aortic complications after esophagectomy for cancer. In the first case, aortic rupture was caused by pyothorax due to residual tumor after esophagectomy. In the second case, aortic rupture was caused by pyothorax due to anastomotic leakage. In the third case, a pseudoaneurysm was caused by surgical injury during esophagectomy. TEVAR was safe and effective for severe aortic complications when graft infection was avoided. The first case died of sepsis on the 84th postoperative day, and the other two cases have survived 4 years and 2 years to date.

Interaction of Rhei Rhizoma extract with cytochrome P450 3A and efflux transporters in rats

Traditional Chinese herbal medicines are frequently prescribed in pharmacotherapy in Japan. In the present study, we evaluated the possible interaction of several herbal extracts including Rhei Rhizoma extract with cytochrome P450 (CYP) 3A and efflux transporters such as P-glycoprotein and multidrug resistance-associated protein (MRP) 2. Rhei Rhizoma extract (100 microg/ml) significantly suppressed the CYP3A-mediated 6beta-hydroxylation of testosterone in hepatic microsomes, and increased the extent of bioavailability of midazolam, a typical CYP3A substrate, in rats. Also, Rhei Rhizoma extract (300 microg/ml) significantly suppressed P-glycoprotein-mediated efflux transport of rhodamine 123 (Rho123) in rat everted intestine. In an in-vivo study, Rhei Rhizoma extract added to intestinal perfusate at a concentration of 300 microg/ml significantly suppressed the intestinal exsorption of Rho123, though it exerted no effect on the biliary excretion of Rho123. Furthermore, the in-vitro and in-vivo MRP2-mediated intestinal efflux of 2,4-dinitrophenyl-S-glutathione was significantly suppressed by Rhei Rhizoma extract (1000 microg/ml). In conclusion, Rhei Rhizoma extract, which is taken orally at doses of 0.5-1 g each or 1-3 g daily in clinical practice, may cause pharmacokinetic herb-drug interactions in the process of the intestinal and/or hepatic CYP3A-mediated drug metabolism and P-glycoprotein- and/or MRP2-mediated efflux transport in the intestine.

Mechanisms underlying the effects of leukocyte apheresis with a fiber filter in a rat model of dextran sulfate sodium-induced colitis

While several clinical trials have suggested that leukocytapheresis (LCAP) by filtration can benefit patients with active ulcerative colitis, the mechanisms underlying these benefits are largely unknown. The aim of this study was to address the mechanisms that may underlie the therapeutic effects of LCAP using a dextran sulfate sodium-induced colitis model in rats. Treatment with the active column, but not the sham column, improved disease severity by down-regulating pro-inflammatory events, including the cell-proliferative responses and inflammatory cytokine and reactive oxygen production, as well as by up-regulating protective events, including hepatocyte growth factor production, bone marrow-derived endothelial progenitor cell induction, and colonic blood flow levels, which were mediated predominantly by calcitonin gene-related peptide. The improvement was also associated with the increase of Ki-67 labeling in the colonic epithelium. In conclusion, the LCAP procedure was used in a dextran sulfate sodium-induced colitis model in rats under extracorporeal circulation conditions. This approach down-regulated pro-inflammatory events and up-regulated protective events in association with disease improvement. These data suggest that LCAP is feasible in animals and should shed light on the mechanisms of LCAP in clinical settings.

[Long-term results of aortic root replacement with a composite graft]

We analyzed the long-term results of aortic root replacement with a composite graft. Since 1992, 127 patients had undergone aortic root replacement with a composite graft. There were 92 men and 35 women with a mean age of 56.5 years. There were 69 patients with annuloaortic ectasia, 17 aortic dissections, and 41 ascending aortic dilatation due to aortic valve disease. Marfan syndrome was diagnosed in 19 patients. As surgical procedure, button technique was used in 90 patients, Cabrol technique in 11, and Piehler technique in 26. Open distal anastomosis was performed in 82 patients to avoid clamp injury of rest aorta. Early mortality was 3.1% and no major morbid events had occurred. Follow-up was completed in 95.9% of the patients and the mean follow-up period was 6.1 years. Actuarial survival at 5, 10, and 15 years was 86.2%, 83.4%, and 83.4%, respectively. Actuarial freedom from aortic valve reoperation at 10 and 15 years was 99.2% and 95.7%, respectively. The results of aortic root replacement with a composite graft were excellent. This procedure should be the 1st choice for surgical treatment of the aortic root disease.

Characterization of temperature-sensitive Akabane virus mutants and their roles in attenuation

Akabane virus (AKAV) of the genus Orthobunyavirus in the family Bunyaviridae is an important animal pathogen; however, studies on AKAV biology are scarce. Therefore, we generated temperature-sensitive (ts) mutants of AKAV in order to study its pathogenesis. The ts AKAV mutants were generated by incubating the virulent OBE-1 strain with the chemical mutagen 5-fluorouracil. Each ts mutant was inoculated intracerebrally into mice to assess its virulence, and the genomic sequences of the attenuated mutants were also determined. Three of the twelve ts mutants studied showed a mortality rate of less than 10%. Although no mutation was detected in the S RNA segment of these three mutants, amino acid substitutions were observed in both the M and L RNA segments. Three of the mutants and the wild-type virus demonstrated a similar pattern of immunoreactivity in an ELISA with anti-Gc monoclonal antibodies. On the other hand, using a minireplicon system, the level of L protein activity of each ts mutant decreased as the temperature increased. These results suggest that the L RNA segment could be involved in the virulence of AKAV, which increases our understanding of how the viral gene products contribute to pathogenesis.

Sequence determination and functional analysis of the Akabane virus (family Bunyaviridae) L RNA segment

Akabane virus (AKAV) causes epizootic congenital deformities in cattle, sheep, and goats. Due to the lack of a complete genome sequence, the molecular biological properties of this virus are not known. We have cloned and sequenced the functional large (L) RNA segment of AKAV, and shown that it has polymerase activity using a minireplicon system with RNA polymerase I. The complete L RNA segment is 6868 nucleotides long and encodes an L protein of 2251 amino acids, which functions as an RNA-dependent RNA polymerase. A minireplicon reporter plasmid was constructed by flanking either the firefly luciferase or the green fluorescent protein gene in the antisense orientation with the 5'- and 3'-terminal noncoding regions of the small RNA segment. HmLu-1 cells were transfected with the reporter plasmid, and the L protein and nucleoprotein (N protein) expression plasmids. The reporter activity was upregulated in a dose-dependent manner with increasing concentration of either the L or N protein expression plasmid. Furthermore, the reporter activity could be downregulated by the AKAV NSs protein as well as by other orthobunyaviruses. These results show that the AKAV minireplicon system is a powerful tool for studying transcription and for rescuing infectious viruses from cloned cDNAs.

Intracellular-diced dsRNA has enhanced efficacy for silencing HCV RNA and overcomes variation in the viral genotype

RNA interference (RNAi) can be used to inhibit viral replication in mammalian cells and therefore could be a powerful new antiviral therapy. Small interfering RNA (siRNA) may be effective for RNAi, but there are some technical problems that must be solved in each case, for example, predicting the effective siRNA target site and targeting heterogeneous sequences in a virus population. We show here that diced siRNA generated from long double-stranded RNA (dsRNA) is highly effective for inducing RNAi in HuH-7 cells harboring hepatitis C virus (HCV) replicons and can overcome variations in the HCV genotype. However, in mammalian cells, long dsRNA induced an interferon response and caused cell death. Here we describe an improvement of this method, U6 promoter-driven expression of long hairpin-RNA with multiple point mutations in the sense strand. This can efficiently silence HCV RNA replication and HCV protein expression without triggering the interferon response or cell death normally caused by dsRNA. In conclusion, intracellular-diced dsRNA efficiently induces RNAi, and, despite the high rate of mutation in HCV, it should be a feasible therapeutic strategy for silencing HCV RNA.

Genetic analysis of calicivirus genomes detected in intestinal contents of piglets in Japan

Enteric caliciviruses, noroviruses, and sapoviruses are emerging pathogens responsible for diarrhea or gastroenteritis in their respective hosts. In this study, swine enteric caliciviruses were detected in ten samples of intestinal contents from 24 piglets in Japan by reverse transcription-polymerase chain reaction using a broadly reactive primer pair (P290/289) that targeted the highly conserved RNA polymerase regions of the enteric caliciviruses. From the positive samples, the entire viral genome of strain K7/JP and 3'-end parts of the genomes of strains K5/JP and K10/JP were cloned and sequenced. K7/JP had an RNA genome of 7144 bases, excluding its 3' poly (A) tail. The K7/JP genome possessed two open reading frames and characteristics common to sapoviruses. In phylogenetic analysis using amino acid sequences of VP1, K5/JP was demonstrated to be close to the noroviruses previously detected in pigs, and K7/JP and K10/JP were considered to be classified as a new genogroup of sapoviruses.

Screening and determination of gene function using randomized ribozyme and siRNA libraries

Rapid progress in the sequencing of the genomes of model organisms, such as the mouse, rat, nematode, fly, and Arabidopsis, as well as the human genome, has provided abundant sequence information, but functions of long stretches of these genomes remain to be determined. RNA-based technologies hold promise as tools that allow us to identify the specific functions of portions of these genomes. In particular, catalytic RNAs, known also as ribozymes, can be engineered for optimization of their activities in the intracellular environment. The introduction of a library of active ribozymes into cells, with subsequent screening for phenotypic changes, can be used for the rapid identification ofa gene function. Ribozyme technology complements another RNA-based tool for the determination of gene function, which is based on libraries of small interfering RNAs (siRNAs).

Genetic recombination at different points in the Npro-coding region of bovine viral diarrhea viruses and the potentials to change their antigenicities and pathogenicities

Cytopathogenic (cp) bovine viral diarrhea virus (BVDV) strain KS86-1 cp was isolated from a cow persistently infected with non-cytopathogenic (ncp) BVDV strain KS86-ncp after development of mucosal disease by superinfection with cp BVDV strain Nose. cp BVDV strains 799cp and 839cp were also isolated from independent cattle that developed mucosal disease by superinfection with cp BVDV KS86-1cp. In the present study, genetic analysis revealed that the genes of cp BVDV strains 799cp and 839cp were chimeras between the genes of the persisting ncp BVDVs and that of superinfecting KS86-1cp. The genetic recombination that generates 799cp occurred between the identical points in the N(pro) gene region, whereas genetic recombination that generates 839cp occurred between different points in the N(pro) gene region. Both 799cp and 839cp were inherited Jiv gene of KS86-1cp strain and envelope protein genes of the persisting viruses. In addition, neutralization test disclosed that antigenicities of 799cp, 839cp, and KS86-1cp were also similar to each persisting virus. These findings indicate that exogenous cp BVDV containing insertion of Jiv gene in the 5 terminal region can induce genetic recombination with the original ncp BVDV at different points in the N(pro) gene region, and those viruses have high potential to change those antigenicities and pathogenicities by RNA recombination.

Enhancement of apoptosis via an extrinsic factor, TNF-alpha, in cells infected with cytopathic bovine viral diarrhea virus

Isolates of bovine viral diarrhea virus (BVDV) are divided into cytopathic (cp) and noncytopathic (ncp) biotypes according to their effect on cultured cells. Calves persistently infected with ncp BVDV are known to develop lethal mucosal disease (MD) after superinfection by cp BVDV. Although the UV-irradiated supernatant of cp BVDV-infected cells has been reported to have no capacity to induce cell death, we found that it could enhance cell death through apoptosis. Up-regulation of tumor necrosis factor alpha (TNF-alpha) and inducible nitric oxide synthase (iNOS) mRNAs was detected specifically in cp BVDV-infected primary cell cultures. Suppression of TNF-alpha via antisense oligonucleotide transfection or incubation with a polyclonal antibody against TNF-alpha resulted in attenuation of apoptosis induced by cp BVDV, suggesting that TNF-alpha participates in apoptosis execution. Although TNF-alpha is one of the iNOS-inducible factors, the iNOS up-regulation was not regulated by TNF-alpha. And iNOS was revealed to serve as anti-apoptotic factor, contrary to our expectation. In addition, the expression level of both TNF-alpha and iNOS mRNAs in the ncp BVDV-infected cells was kept lower than that in the mock-infected cells, suggesting that ncp BVDV reduced or interfered with the factor triggering the expression of both mRNAs. These characteristic mRNA transcriptions would help to explain why BVDV acts differently in cells as well as in vivo, depending on its biotype. To elucidate viral factors inducing TNF-alpha and iNOS may be critical to understand the mechanism of MD development, which closely correlates with cp BVDV-induced apoptosis.

A novel antigenic variant of Canine parvovirus from a Vietnamese dog

Nine isolates of Canine parvovirus (CPV) were obtained from Vietnamese dogs and cats. One canine isolate showed a unique antigenic property which indicates a novel antigenic variant of CPV-2b when examined with hemagglutination inhibition tests using our monoclonal antibodies, 21C3 and 19D7, which were recently developed. This isolate had an amino acid substitution of residue 426, Asp to Glu, and the same substitution has recently been found in CPV from Italian dogs. This study first showed that such substitution caused an antigenic difference demonstrable by monoclonal antibodies and that a similar evolution may have occurred in CPV in Vietnam.

Identification of Structurally Diverse Growth Hormone Secretagogue Agonists by Virtual Screening and Structure−Activity Relationship Analysis of 2-Formylaminoacetamide Derivatives

Two molecules with known growth hormone secretagogue (GHS) agonist activity were used as templates to computationally screen approximately 80000 compounds. A total of 108 candidate compounds were selected, and five of them were found to be active in the low-micromolar range in both cell-based and direct binding assays. These compounds were structurally diverse and significantly differed from known GHS agonists. The most active compound was subjected to SAR evaluation, which slightly increased its potency and identified molecular regions important for specific GHS agonist activity.

Obstruction of St Jude medical valves in the aortic position: a consideration for pathogenic mechanism of prosthetic valve obstruction

Between 1995 and 2000, 8 patients with St. Jude Medical (SJM) valves in the aortic position required 9 redo valve replacement for prosthetic valve obstruction. Obstruction of the prosthetic valve was diagnosed by simultaneous echocardiography and cineradiography, and process of restricted leaflet movement that progressed to hemodynamic impairment was observed by serial studies in three recent patients. An oral anticoagulation was considered to be adequate in all patients except one patient who had withdrawal of warfrain. Pannus was the sole cause of valve obstruction in seven events in 6 patients, and both thrombus and pannus in 2 patients. Pannus overgrowth was found on the inflow aspect of the SJM valve, and involved the ends of the straight edge of the leaflets over pivot guards. These results suggest that pannus might play the primary role in development of obstruction of aortic SJM valves in patients on adequate oral anticoagulation.

[Long-term results of aortic root replacement for Marfan syndrome]

Between January 1974 and December 2000, aortic root replacement was performed for 46 patients with Marfan syndrome. The hospital mortality rate amounts to 8.6% (4 patients out of 46). Fifteen (35.7% of survivor) of 42 survivor died during the period of follow-up. Eighteen of 42 survivor were developed cardiovascular events of 21 times and 11 patients had to be reoperated on at least once for a total of 12 reoperations. Nine of 15 late death patient died in relation to aortic dissection and pseudoaneurysm of distal anastomosis and coronary anastomosis. Actuarial survival rate was satisfactory for 10 years after aortic root replacement, but sharply decreased after postoperative 10 years. The use of non-sealed graft, classical Bentall method, reoperation and inclusion technique were risk factors for the late death.

Suppression of gene expression by RNA interference in cultured plant cells

Suppression by double-stranded RNA (dsRNA) of the expression of a target gene is known as RNA interference (RNAi). No quantitative analysis of the effects of RNAi on the expression of specific genes in cultured plant cells has been reported. However, as it is possible to produce populations of cultured plant cells that are uniform and divide synchronously for functional analysis of genes of interest, we performed a quantitative study of the effects of RNAi in such cells. We constructed dsRNA expression plasmids for a luciferase gene under the control of the cauliflower mosaic virus (CaMV) 35S promoter by simply connecting sense and antisense sequences in a head-to-head manner. An RNAi effect was observed 24 hours after the introduction of dsRNA expression plasmids into tobacco BY-2 cells by electroporation. The simple system for suppression of specific genes in plant cells should be useful in attempts to elucidate the roles of individual genes in plant cells.

Gene expression and molecular evolution

The combination of complete genome sequence information and estimates of mRNA abundances have begun to reveal causes of both silent and protein sequence evolution. Translational selection appears to explain patterns of synonymous codon usage in many prokaryotes as well as a number of eukaryotic model organisms (with the notable exception of vertebrates). Relationships between gene length and codon usage bias, however, remain unexplained. Intriguing correlations between expression patterns and protein divergence suggest some general mechanisms underlying protein evolution.

Cross reaction of recombinant equine infectious anemia virus antigen to heterologous strains and application for serological survey among horses in the field

Cross reactivity of equine infectious anemia virus (EIAV) antigen prepared using a recombinant baculovirus containing the p26 gene of strain P337-V70 was examined by the agar gel immunodiffusion (AGID) test and enzyme-linked immunosorbent assay (ELISA). Serum samples serially collected from 13 horses experimentally infected with six different EIAV strains (two or three horses per strain) were subjected to the test. Positive reactions were observed in the AGID test and ELISA before or soon after the first feverish period and continued persistently in most of the horses. The results with recombinant antigens were essentially the same as those with the virion antigen prepared from horse cell cultures both in the AGID test and ELISA. The reactivities of the antigens were further compared using serum samples collected from horses in 1999 in certain districts of Mongolia where equine infectious anemia has been prevalent, and from horses in Japan in 1973 when EIA had not been eliminated completely from Japanese horses. These results were completely concurrent. Generally, recombinant antigens have high specificity but low cross reactivity to heterologous strains. However, the present study showed that the recombinant EIAV p26 antigen has cross reactivity to the heterologous strain and is useful for diagnosis of EIA in the field.

Unruptured aneurysm of the right coronary sinus of Valsalva with type B aortic dissection

A seventy-two year-old man, who complained of severe back pain, was referred to our hospital. Digital subtraction angiogram (DSA) delineated an extracardiac unruptured aneurysm of the right coronary sinus of Valsalva and acute type B aortic dissection. Patch plasty of the right coronary sinus with reimplantation of the right coronary artery using a Dacron graft was performed. Postoperative DSA confirmed successful reconstruction of the aortic root and the patent right coronary artery.

Surgical management of a graftenteric fistula: a modified method of in situ reconstruction

Between December 1989 and May 1998, we performed a modified method of in situ reconstruction on three of seven patients with graftenteric fistulas (GEFs) at the Kurume University Hospital. The modification involved performing an anastomosis of the infrarenal abdominal aorta and running a new prosthesis through the left side of the descending colon in the retroperitoneal cavity, and wrapping the proximal anastomosis and the proximal site of the prosthesis in the greater omentum. Good results were achieved in all three patients. We describe herein this modified method of in situ reconstruction for a GEF and summarize the case reports of these three patients.

Genomic and serological diversity of bovine viral diarrhea virus in Japan

Genomic properties of 62 field isolates of bovine viral diarrhea virus (BVDV) collected from 1974 to 1999 in Japan were investigated. The 5' untranslated region (UTR) was amplified by reverse transcriptase-polymerase chain reaction (RT-PCR) and the 244 to 247 base nucleotide sequences were determined. Serological properties were also characterized by the cross-neutralization test using antisera against the representative strain of the classified genotype. Using phylogenetic tree analysis, BVDV 1 was subdivided into two major clusters, BVDV-1a (29 isolates) and BVDV-1b (27 isolates). In group 1a, 3 differed from the other viruses, and were classified in a branch assigned as 1a'. However, 4 isolates (So CP/75, 190 CP, 190 NCP and KS86-1-NCP) could not be assigned to group 1a or 1b. In comparison with the published sequence data, KS86-1-NCP, 190 CP and 190 NCP were similar to the Southern Africa isolates that have recently been proposed as BVDV 1c. The 5' UTR sequence of So CP/75 was unique among those of BVDV 1, suggesting that the isolate should be classified into a new genotype. Only 2 out of 62 isolates collected in 1989 and 1990 were identified as BVDV 2. The results of the cross-neutralization test strongly supported these data, suggesting a close correlation between the 5' UTR sequence and the antigenicity of BVDV.

Measurement of circulating biliary glycoprotein (CD66a) in liver diseases

PURPOSE

Biliary glycoprotein (BGP), a member of the carcinoembryonic antigen (CEA) gene family, is produced by hepatocytes, and is suggested to function as a cell adhesion molecule, mouse hepatitis virus receptor, and tumor suppressor. Our aim was to establish an enzyme immunoassay for circulating BGP and to study its significance in liver diseases.

METHODS

For enzyme immunoassay, a monoclonal antibody (mAb), TS135, which recognizes BGP was used as a catcher, and biotin-labeled polyclonal anti-CEA antibodies were used as a tracer. Seventy-six serum specimens obtained from patients with various liver diseases were submitted to the assay.

RESULTS

The incidence of positivity for antigen TS135 in the serum samples of the 76 patients was 57.9%. The most significant correlation among conventional liver function tests was found between antigen TS135 and gamma-glutamyl transpeptidase (gamma-GTP). However, among the 56 patients whose serum antigen TS135 and gamma-GTP levels could be measured simultaneously, 5 were antigen TS135-positive and gamma-GTP-negative (8.9%) and 6 were antigen TS135-negative and gamma-GTP-positive (10.7%). The increased serum level of antigen TS135 in 6 cholangiocellular carcinoma (CCC) patients led us to the immunohistochemical study of CCC, in which 8 of the 8 tissue specimens tested were positive for mAb TS135, indicating the production of the antigen from CCCs.

CONCLUSIONS

This preliminary study suggests that the circulating antigen TS135 level correlates with gamma-GTP in liver diseases, but that TS135 may also have a unique significance, different from that of gamma-GTP, as a liver function test.

Repair of left ventricular rupture following mitral valve replacement concomitant with left atrial reduction procedure--intracardiac patch and extracardiac buttress suture

Rupture of the posterior wall of the left ventricle after mitral valve replacement is a dire complication associated with a very high mortality. This study reports a successful repair of type I left ventricular rupture, which occurred after mitral valve replacement concomitant with a left atrial reduction procedure, by combination of an intracardiac patch and an extracardiac buttress suture. In a case such as this, in which hemostasis is quite difficult to establish, this combination technique is particularly effective.

Surgical treatment for graft stenosis after repair of an interrupted aortic arch: report of two cases

We report herein two cases of patients who underwent successful reoperation for graft stenosis after repair of an interrupted aortic arch (IAA). The first patient was a 10-year-old girl who suffered from upper limb hypertension 9 years after her initial operation. Cardiac catheterization revealed a pressure gradient of 55 mmHg across the repaired arch. At reoperation, a left subclavian turndown anastomosis was performed, following which the hypertension resolved and a cardiac catheterization done 5 years later demonstrated sufficient growth of the restored arch with no significant gradient. The second patient was a 17-year-old boy who suffered from general fatigue and intermittent hypertension 12 years after his initial operation. Cardiac catheterization revealed a gradient of 60 mmHg across the repaired arch. He underwent an extraanatomic ascending to descending aortic bypass employing an additional 18-mm graft, and a postoperative cardiac catheterization showed no gradient between the ascending and descending aorta. Our experience has shown that IAA should be repaired without prosthetic grafts if possible. Although extraanatomic bypass is useful for reducing the operative risks at reoperation, a large graft should be used to avoid the need for a third operation. For young children expected to outgrow a second graft, performing an endogenous anastomosis, such as a left subclavian turndown anastomosis, should be considered as an alternative.

Cardio-aortic operation in octogenarians

OBJECTIVE

Aging of the population is a current phenomenon in Japan, and life expectancy at 80 years old is getting longer. So we reviewed cardio-aortic operations on octogenarians at our institution.

SUBJECTS AND METHODS

Thirty-three consecutive octogenarian patients who had undergone cardio-aortic operations from 1992 to 1998 were studied. There were 14 men and 19 women. The mean age was 81.9 years. Of the 33, 19 patients (58%) were in New York Heart Association class IV, and 21 patients (64%) were operated on urgently or in emergency. The procedures undergone were operation for coronary artery disease in 17 patients, operation for valvular disease in 7 patients, operation for thoracic-aorta in 7 patients, and others in 2 patients.

RESULTS

The hospital mortality rate was 27% (9 patients). However, 89% of patients experiencing hospital death were in New York Heart Association class IV preoperatively and had required an emergency/urgent operation. On the other hand, there was only one hospital death (1/12, 8.3%) among the elective patients. The statistically significant risk factors for hospital death were renal insufficiency, shock, New York Heart Association class IV, intra-aortic balloon pumping, and longer cardiopulmonary bypass time. The one-, three-, and five-year-survival rate was 73%, 68%, and 55%, respectively. Of the survivors, 77% were in class I or II.

CONCLUSION

Although octogenarians' hospital mortality was still very high, the mid-term results were acceptable and the survivors' quality of life was satisfactory. These data suggested that we should operate on cardio-aortic patients before they reach a very serious state, especially in octogenarians.

A simple and rapid system for the quantitation of RNA interference in plant cultured cells

The phenomenon known as RNA interference (RNAi) by double-stranded RNA (dsRNA) that was reported recently in the nematode Caenorhabditis elegans has been shown to operate by a mechanism that is widely conserved among species including plant cells. No quantitative analysis of the effects of RNAi on the expression of specific genes in plant cultured cells has been reported. An RNAi effect was observed 24 h after the introduction of dsRNA expression plasmids into tobacco BY-2 cells by electroporation. The simple system for suppression of specific genes in plant cells should be useful in attempts to elucidate the roles of individual genes in plant cells.

A test of translational selection at 'silent' sites in the human genome: base composition comparisons in alternatively spliced genes

Natural selection appears to discriminate among synonymous codons to enhance translational efficiency in a wide range of prokaryotes and eukaryotes. Codon bias is strongly related to gene expression levels in these species. In addition, between-gene variation in silent DNA divergence is inversely correlated with codon bias. However, in mammals, between-gene comparisons are complicated by distinctive nucleotide-content bias (isochores) throughout the genome. In this study, we attempted to identify translational selection by analyzing the DNA sequences of alternatively spliced genes in humans and in Drosophila melanogaster. Among codons in an alternatively spliced gene, those in constitutively expressed exons are translated more often than those in alternatively spliced exons. Thus, translational selection should act more strongly to bias codon usage and reduce silent divergence in constitutive than in alternative exons. By controlling for regional forces affecting base-composition evolution, this within-gene comparison makes it possible to detect codon selection at synonymous sites in mammals. We found that GC-ending codons are more abundant in constitutive than alternatively spliced exons in both Drosophila and humans. Contrary to our expectation, however, silent DNA divergence between mammalian species is higher in constitutive than in alternative exons.

Growth-suppressive effect of non-steroidal anti-inflammatory drugs on 11 colon-cancer cell lines and fluorescence differential display of genes whose expression is influenced by sulindac

In addition to an anti-inflammatory effect, sulindac, one of the non-steroidal anti-inflammatory drugs (NSAIDs), has been shown to have a protective effect against the incidence and mortality of colorectal cancer. However, the molecular basis of its anti-proliferative function remains unclear. To investigate its molecular mechanism, we exposed 11 colon-cancer cell lines to NSAIDs such as aspirin, sulindac and the sulfide and sulfone metabolites of sulindac. Sensitivity to these drugs was dose- and time-dependent but varied from one cell line to another. Among the cell lines examined, sulindac showed a moderate anti-proliferative effect on HT-29 colon cancer cells and caused morphological changes, including an increase of cells with abnormal DNA content. We used the mRNA fluorescence differential display method with these cells to identify molecules that might contribute, through altered expression, to cellular changes in response to NSAIDs. Sixty-eight cDNA fragments were confirmed by RT-PCR to have significantly different expression levels following sulindac treatment. Thirty of these fragments proved to be novel cDNA sequences or identical to expressed sequence tags; the other 38 fragments were identical, or showed significant homology, to genes whose function was already known. Among the known genes differentially expressed in HT-29 cells after sulindac treatment were those encoding acetylglucosaminyltransferase, ferritin heavy chain, zinc finger protein 165, aldose reductase, carcinoembryonic antigen, aldoketoreductase, NF-kappaB-activating kinase, lysosome-associated protein, RhoE = 26 kDa GTPase homologue, NADH oxidoreductase, G/T mismatch bindingprotein, TM7SF3, ADP/ATP carrier-like protein and chromosome segregation protein. This variety among classes of proteins affected by sulindac in our experiments underscores the complexity of anti-proliferative mechanisms that may operate in colon-cancer cells treated with NSAIDs. Furthermore, identification of genes regulated by NSAIDs in colon-cancer cells should provide useful information to identify novel therapeutic targets for treatment and/or prevention of colon cancer.

Cerebral protection selection in aortic arch surgery for patients with preoperative complications of cerebrovascular disease

OBJECTIVE

Retrograde perfusion is gaining acceptance as a means of cerebral protection, but it remains unclear how long the brain is protected and whether it is effective in patients with preoperative cerebrovascular disease.

METHODS

From January 1989 to August 1999, 205 patients--118 male and 87 female patients who ranged 12 to 86 years old, mean: 65.5 years old--underwent surgery at our hospital for aortic arch aneurysm using cerebral protection. We focused on mortality, stroke incidence and perioperative risk factor between 2 groups--selective cerebral and retrograde cerebral perfusion--also studying patients with preoperative cerebrovascular disease that influenced postoperative stroke.

RESULTS

The hospital mortality was 11.7% (selective cerebral perfusion group: 12%, retrograde group: 10.9%). Stroke occurred in 11 patients (5.3%), 4.7% in the selective cerebral perfusion group and 7.3% in the retrograde group. Preoperative cerebrovascular disease does not appear to be a risk factor for postoperative brain damage in aortic arch surgery. Regarding total replacement of the aortic arch, the incidence of postoperative brain damage in the retrograde group with preoperative cerebrovascular disease was higher than that in another group (p = 0.072). Cardiopulmonary bypass time and selective cerebral perfusion time in the patients with postoperative stroke were significantly longer than that in non-stroke group.

CONCLUSIONS

Preoperative cerebrovascular disease did not appear to be a risk factor in postoperative neurological deficit in the selective cerebral perfusion group. Prolonged selective cerebral perfusion time and cardiopulmonary bypass time may, however, lead to brain edema and cause neurological deficit.