Cardiac Reversibility and Survival After Transcatheter Aortic Valve Implantation in Patients With Low-Gradient Aortic Stenosis

Background Prognostic implications of transcatheter aortic valve implantation (TAVI) in low-gradient (LG) aortic stenosis (AS) remain controversial. The authors hypothesized that differences in cardiac functional recovery may solve this ongoing controversy. The aim was to evaluate clinical outcomes and the response of left ventricular (LV) function following TAVI in patients with LG AS. Methods and Results This multicenter retrospective study included 1742 patients with severe AS undergoing TAVI between January 2015 and March 2019. Patients were subdivided into low-flow (LF) LG, normal-flow (NF) LG, LF high-gradient, and NF high-gradient AS groups according to the mean gradient of the aortic valve (LG <40 mm Hg) and LV stroke volume index (LF <35 mL/m2). Outcomes and changes in echocardiographic parameters after TAVI were compared between the groups. A total of 227 patients (13%) had reduced ejection fraction, and 486 patients (28%) had LG AS (LF-LG 143 [8%]; NF-LG 343 [20%]). During a median follow-up period of 747 days, 301 patients experienced a composite end point of cardiovascular death and rehospitalization for cardiovascular events, which was higher in the LF-LG and NF-LG groups than in the high-gradient groups. LG AS was independently associated with the primary outcome (hazard ratio, 1.69; P<0.001). Among 1239 patients with follow-up echocardiography, LG AS showed less improvement in the LV mass index and LV end-diastolic volume compared with high-gradient AS after 1 year, while LV recovery was similar between the LF AS and NF AS groups. Conclusions LG AS was associated with poorer outcomes and LV recovery, regardless of flow status after TAVI. Careful evaluation of AS severity may be required in LG AS to provide TAVI within the appropriate time and advanced care afterward.

Survey results: status report on problems caused by sexual mismatch between sonographer and patient during echocardiography-a 2020 report of the Japanese Society of Echocardiography

OBJECTIVES

Ultrasonography is an essential examination performed in various clinical fields. The number of clinical sonographers has been increasing. However, the working environments and conditions at each facility are different, leading to diverse problems. Among them, the emerging issue is the sexual disagreement between the sonographer and patient at the time of echocardiography. Since the patient must expose their breast during echocardiography, female patients may refuse to undergo the examination when conducted by a male sonographer. This study aimed to conduct a questionnaire survey to understand the measures for sonographer-patient gender mismatch at different facilities.

METHODS

A questionnaire on the implementation of echocardiography by male sonographers for female patients was answered by representatives and specialist technicians of the Japanese Society of Echocardiography.

RESULTS

Questionnaire responses were obtained from 50 facilities (59 participants). A total of 70% of the facilities restricted male sonographers from conducting echocardiography examinations for female patients. Among them, 81% of the facilities serviced female patients aged 60 years or younger.

CONCLUSIONS

It has become clear that the gender selection of echocardiographic examiners varies from facility to facility, and providing a sufficient explanation before echocardiographic examination is necessary to avoid causing uncomfortable situations for female patients.

Evaluation of large airway specimens obtained by transbronchial lung cryobiopsy in diffuse parenchymal lung diseases

Background

The difference in diagnostic yield between surgical lung biopsy and transbronchial lung cryobiopsy (TBLC) in diffuse parenchymal lung diseases (DPLD) has been reported to be due to differences in the rate of interpathologist agreement, specimen size, and specimen adequacy. In TBLC, the specimens containing large airway components are generally believed as inadequate specimens for histological evaluation, but the detailed characteristics of TBLC specimens including the large airway and the impact on histological diagnostic rates of DPLD have not been investigated.

Methods

We retrospectively reviewed the specimen characteristics of patients with DPLD who underwent TBLC.

Results

Between February 2018 and January 2020, 74 patients and 177 specimens were included. There were 85 (48.0%) large airway specimens (LAS) that contained bronchial gland or bronchial cartilage. The ideal specimen ratio was significantly lower in the LAS-positive group than that in the LAS-negative group (5.8% vs. 45.6%), and the proportion of bronchioles, alveoli, and perilobular area were similarly lower in the LAS-positive group. The presence of traction bronchiectasis and diaphragm overlap sign on high-resolution computed tomography (HRCT) were also significantly higher in the LAS-positive group than those in the LAS-negative group. We observed a statistically significant trend in histological diagnostic yield (40.7% in LAS positive group; 60.8% in LAS positive and negative group; 91.6% in LAS negative group) (Cochran-Armitage trend test).

Conclusion

LAS is a specimen often collected in TBLC and contains a low percentage of bronchioles, alveoli, and perilobular area. Since the histological diagnostic yield tends to be higher in cases that do not contain LAS, it may be important to determine the biopsy site that reduces the frequency of LAS collection by referring to the HRCT findings in TBLC.

Back somersault-induced atrioventricular nodal reentrant tachycardia - A case of a 15-year-old promising gymnast

A male 15-year-old promising gymnast suffered palpitations, which emerged only after landing a round-off back somersault. The performance induced an attack of regular narrow QRS complex tachycardia that was highly reproducible. Not a single element of the performance, but a whole sequence of round-off back somersault was required to induce the attack. An electrophysiologic study revealed an intra-nodal dual pathway causing atrioventricular nodal reentrant tachycardia (AVNRT). A complication of a tiny atrial septal defect (ASD) was incidentally detected, thus we initially suspected a causal relation of ASD as the platypnea-orthodeoxia syndrome. However, it was denied as the major mechanism of attack because of a very faint shunt flow and no-induction of hypoxemia during a round-off back somersault. The major triggering mechanisms of a whole sequence of round-off back somersaults were speculated to be related to transient atrial overload and autonomic imbalance induced by a swift postural-axial change together with an intense Valsalva maneuver with the maximal level of breath holding. The AVNRT attack was successfully treated by radiofrequency catheter ablation and has never recurred even by a whole sequence of round-off back somersaults. Currently he is a healthy and active gymnast with no symptoms. <Learning objective: The individual trigger of an atrioventricular nodal reentrant tachycardia (AVNRT) attack varies. The unique and sole trigger of the attack in the present gymnast case was a whole sequence of round-off back somersaults. A swift postural-axial change together with an intense Valsalva maneuver with the maximal level of breath holding increased the atrial overload with stretching the atrial wall, which might have induced atrial extrasystole and played a trigger role initiating the AVNRT attack.>.

Antimitochondrial Antibody-associated Myopathy with Slowly Progressive Cardiac Dysfunction

A 45-year-old woman was referred to our hospital for the evaluation of proximal muscle weakness and serum creatine kinase elevation [corrected]. She had atrial fibrillation and left ventricular asynergy. She was diagnosed with myopathy, accompanied by cardiomyopathy of unknown etiology. She was treated with prednisolone. After long-term follow-up and a detailed examination, the patient was diagnosed with antimitochondrial antibody (AMA)-associated myopathy with cardiac involvement. Although the patient received medical treatment, including beta-blockers and prednisolone, her cardiac function deteriorated progressively. Physicians should consider AMA-associated myopathy when diagnosing myopathies of unknown etiology. The presence of cardiac involvement should be proactively investigated in AMA-associated myopathy.

The Incidence and Risk Factors of Venous Thromboembolism in Patients with Inflammatory Bowel Disease: A Prospective Multicenter Cohort Study

BACKGROUND

Venous thromboembolism (VTE) has been shown to be more frequent in inflammatory bowel disease (IBD) than in the general population in Western studies. However, the actual state of VTE in Asian IBD remains poorly understood.

AIMS

To reveal the incidence of VTE in IBD patients in Japan.

METHODS

Eighty-five patients admitted to 3 gastroenterology centers were registered from 2013 to 2018. The incidence of VTE in patients with IBD (n = 42) was prospectively compared to that among patients with other digestive diseases (n = 43). The presence of VTE was surveyed using contrast-enhanced computed tomography and/or ultrasonography at admission and at 1-2 weeks after admission. The patient characteristics and laboratory data of IBD patients with or without VTE were compared to determine the risk factors for VTE.

RESULTS

The incidence of VTE with IBD was 16.7%, which was significantly more frequent than with other digestive diseases (2.3%; p = 0.0296). In IBD patients, VTE was detected in 6 of 22 patients with ulcerative colitis (27.2%) but in only 1 of 20 patients with Crohn's disease (5.0%). VTE was diagnosed at admission in 4 IBD patients and 2 weeks after admission in 3 IBD patients. The risk factors of VTE in IBD were the presence of an indwelling central venous catheter, a low level of total protein, a low activated partial thromboplastin time, and a high level of fibrinogen degradation products.

CONCLUSION

VTE was frequently detected in Japanese IBD patients both at and after admission. Adequate screening and prophylaxis for VTE is deemed necessary in IBD.

Examination of Anterior Leaflet Pseudoprolapse Causing Severe Mitral Regurgitation and Its Ideal Surgical Procedure

BACKGROUND

The aim of this study is to evaluate severe mitral regurgitation caused by so called atrial leaflet "pseudoprolapse" and verify the effect of simple annular stabilization.

METHODS

One-hundred-twenty-two patients underwent surgery for severe mitral regurgitation at our institute between January 2015 to July 2018. Of those, 32 cases diagnosed as anterior leaflet prolapse that underwent mitral repair were analyzed. Ten cases with pseudoprolapse, which is defined as anterior leaflet prolapse without dropping into the left atrium beyond the annular line causing eccentric regurgitation flow directed to the posterior atrium, were classified as the Pseudoprolapse Group. The other 22 cases had obvious anterior leaflet prolapse dropping into the left atrium; these cases were classified as the True Prolapse Group. We compared clinical findings between the 2 groups and reviewed pseudoprolapse cases.

RESULTS

Patients in the Pseudoprolapse Group had lower ejection fraction and lower regurgitation volume than those in the True Prolapse Group. A2 lesion as main inflow of regurgitation was more included in the Pseudoprolapse Group. All but one patient in the Pseudoprolapse Group received only simple annuloplasty, and all patients in the True Prolapse Group received leaflet repair and annuloplasty. In both groups, mid-term regurgitation grade and the reoperation rate were satisfactory. In the Pseudoprolapse Group, 6 cases were clarified as atrial functional mitral regurgitation, and 4 cases were considered to have focal posterior leaflet tethering.

CONCLUSIONS

Pseudoprolapse cases could be characterized by low ejection fraction, low regurgitation volume, and A2 prolapse. For most cases with pseudoprolapse, simple annuloplasty may be enough, however further study is needed.

Autoimmune pulmonary alveolar proteinosis developed during immunosuppressive treatment in polymyositis with interstitial lung disease: a case report

Background

Pulmonary alveolar proteinosis (PAP) is characterized by the accumulation of surfactant proteins within the alveolar spaces. Autoimmune PAP (APAP) caused by elevated levels of GM-CSF autoantibodies (GM-Ab) is very rarely associated with systemic autoimmune disease. Here we report a case of APAP manifested during immunosuppressive treatment for polymyositis with interstitial lung disease.

Case presentation

A 52-year-old woman treated at our hospital because of polymyositis with interstitial pneumonia had maintained remission by immunosuppressive treatment for 15 years. She had progressive dyspnea subsequently over several months with her chest CT showing ground-glass opacities (GGO) in bilateral geographic distribution. Her bronchoalveolar lavage fluid with cloudy appearance revealed medium-sized foamy macrophages and PAS-positive amorphous eosinophilic materials by cytological examination. We diagnosed her as APAP due to an increased serum GM-CSF autoantibody level. Attenuating immunosuppression failed to lead GGO improvement, but whole lung lavage (WLL) was effective in her condition.

Conclusions

PAP should be considered as one of the differential diseases when the newly interstitial shadow was observed during immunosuppressive treatment. WLL should be regarded as the treatment option for APAP concurred in connective tissue disease (CTD).

Anti-signal Recognition Particle Antibody-positive Necrotizing Myopathy with Secondary Cardiomyopathy: The First Myocardial Biopsy- and Multimodal Imaging-proven Case

A 69-year-old Japanese woman was admitted to our hospital with progressive muscle weakness and dysphagia. She was taking pitavastatin for dyslipidemia. Her serum creatine kinase was 6,300 U/L. Pitavastatin was stopped, but her symptoms deteriorated, and cardiac congestion appeared. A muscle biopsy showed necrotizing myopathy (NM), and anti-signal recognition particle (SRP) antibody was positive. ¹⁸F-fluorodeoxyglucose-positron emission tomography showed an abnormal uptake, and magnetic resonance imaging showed abnormal gadolinium enhancement in the left ventricular wall. An endomyocardial biopsy revealed inflammatory cardiomyopathy. Steroid, tacrolimus, and intravenous immunoglobulins were effective against the symptoms. This is the first case of biopsy-proven secondary cardiomyopathy due to anti-SRP-positive NM.

Cerebral Microbleeds Remain for Nine Years: A Prospective Study with Yearly Magnetic Resonance Imaging

BACKGROUND

Cerebral microbleeds (CMBs) are refined neuroimaging findings detected on T2*-weighted gradient echo (GRE) magnetic resonance imaging (MRI) and are widely accepted as an important marker of the vulnerability of cerebral small vessels. It is necessary to further clarify the natural history of CMBs by a longitudinal study. This study aimed to reveal the natural history of CMBs and find a better way to track CMBs by a prospective long-term observation.

METHODS

We performed yearly brain MRI assessments for 7 or more years in 8 nonvalvular atrial fibrillation Japanese outpatients with CMBs detected in the baseline MRI. We began to use a 3.0T MRI scanner from 2012 as well.

RESULTS

We followed up 3 patients for 9 years, 2 for 8 years, and 3 for 7 years. In all patients, the CMBs at baseline did not disappear during the follow-up period. Importantly, the CMB in 1 patient seemed to disappear during the sixth imaging using 1.5T T2*-weighted GRE but was detected again during the seventh imaging with 3.0T susceptibility weighted imaging and ninth imaging with 3.0T T2* GRE. Moreover, in a patient implanted with a pacemaker, which is only applicable for 1.5T MRI at present, the CMB seemed to disappear and appeared once again with a 1.5T T2*-weighted GRE at a slice thickness of 2.5 mm instead of 5 mm.

CONCLUSIONS

From this prospective study, we obtained 2 absolutely new findings that CMBs remained for as long as 9 years and a high-field or thin-slice MRI can detect concealed CMBs.

Bow Hunter syndrome elicited by vertebral arterial occlusion after total arch replacement

An 83-year-old man with arch aneurysm underwent total arch replacement with frozen elephant trunk and extra-anatomical left subclavian artery bypass. One year later, he felt dizziness associated with head rotation. The hypoplastic left vertebral artery was occluded by a thrombus extending from the left subclavian artery ligation site, and the dynamic stenosis of right vertebral artery by head rotation induced dizziness. He was diagnosed with Bow Hunter syndrome. Vertebral artery hypoplasia represents a possible cause of this rare complication. To the best of our knowledge, this is the first report describing Bow Hunter syndrome after total arch replacement.

Selective extraction of Pd(ii) by p-tert-butylcalix[4]arenedicarboxylic acid

p-tert-Butylcalix[4]arenedicarboxylic acid, in which two distal hydroxy groups of p-tert-butylcalix[4]arene are replaced with carboxy groups, shows extraction selectivity toward Pd²⁺ ions by the formation of a 2 : 2 (M/L) complex.

Late Gadolinium Enhancement on Cardiac MRI Correlates with QT Dynamicity Represented by QT/RR Relationship in Patients with Ventricular Arrhythmias

BACKGROUND

The distribution of late gadolinium enhancement (LGE) on the cardiac MRI (CMR) indicates myocardial fibrosis and provides information of possible reentry substrates. QT dynamicity reflecting repolarization abnormalities has gained attention as a potential prognostic predictive factor.

OBJECTIVE

To clarify the correlation between the LGE distribution on CMR and QT dynamicity represented by the QT/RR relationship.

METHODS

CMR and QT/RR analyses using Holter monitoring were performed in 34 patients (24 males, 60 ± 11 years) with ventricular tachycardia (VT) and/or ventricular fibrillation (VF). The LGE on CMR was scored using a 4-point score in 17 left ventricular segments. The sum of the LGE scores was calculated for each patient. The QT/RR slope and daytime/nighttime QT/RR ratio (day/night ratio) were calculated. The correlation between the slope or the day/night QT/RR ratio and late enhancement findings was analyzed.

RESULTS

All patients were divided into 23 LGE positive (LGE(+)) and 11 LGE negative (LGE(-)) patients. The slopes of the QTe/RR and QTa /RR were significantly steeper in the LGE(+) than in LGE(-) patients (0.21 ± 0.03 vs 0.13 ± 0.02; P < 0.001, 0.19 ± 0.03 vs 0.13 ± 0.02; P < 0.001, respectively), and both slopes were significantly correlated with the total LGE scores (r = 0.83, P < 0.001; r = 0.71, P < 0.001, respectively). In the LGE(+) patients, the QTe day/night (1.37 ± 0.38 vs 0.91 ± 0.33; P = 0.002) and QTa day/night ratios (1.33 ± 0.26 vs 1.06 ± 0.30; P = 0.011) were significantly greater than those in the LGE(-) patients.

CONCLUSION

The LGE distribution was closely related to the QT dynamicity, suggesting that a combination of these markers can be a powerful tool for understanding the background pathophysiology.

Repolarization characteristics in early repolarization and brugada syndromes: insight into an overlapping mechanism of lethal arrhythmias

INTRODUCTION

We reported impaired QT-rate dependence in early repolarization syndrome (ERS); however, contemporary data have shown peak incidence of sudden cardiac death (SCD) in ERS and Brugada syndrome (BrS) at mid-night and early morning. Taken together, we analyzed the nocturnal QT-rate dependence in both syndromes.

METHODS AND RESULTS

A total of 172 subjects were enrolled: 11 ERS, 11 BrS patients, 50 subjects with an uneventful ER pattern (ERP), and 100 non-J-wave control subjects. Ambulatory ECG-derived parameters (QT, QTc, and QT/RR slope) and day-night QT difference were analyzed and compared. Among the groups, there was no significant difference in the average QT or QTc; however, the 24-hour QT/RR slope was significantly smaller in ERS and BrS patients (0.103 ± 0.01 and 0.106 ± 0.01, respectively) than in the control group (0.156 ± 0.03, P < 0.001). Detailed analysis showed a lower day-night QT difference in ERS and BrS patients (19 ±18.7 and 24 ±14 milliseconds, respectively) than in the controls (40 ± 22 milliseconds, P = 0.007) with the lowest QT/RR slopes seen in the ERS and BrS groups from 0 to 3:00 am (QT/RR; 0.076 ± 0.02 vs. 0.092 ± 0.04 vs. 0.117 ± 0.04, for the ERS, BrS, and controls, respectively, P = 0.004) and from 3 to 6 am (QT/RR 0.074 ± 0.03 vs. 0.079 ± 0.02 vs. 0.118 ± 0.04, P < 0.001).

CONCLUSION

In a large population of age- and gender-matched groups, both ERS and BrS patients showed attenuated QT-rate dependence and impaired QT day-night modulation that may provide a baseline reentrant substrate. Importantly, QT/RR maladaptation was most evident at mid-night and early morning, which may explain the propensity of such patients to develop SCD during this critical period.

[Performance of two matrix-assisted laser desorption/ionization time of flight mass spectrometry (MALDI-TOF MS) models for identification of bacteria isolated from blood culture]

We compared the results of two bacterial identification methods: 1) a traditional method based on phenotypic identification of the causative organism using gram-staining, culture and biochemical markers and 2) matrix-assisted laser desorption/ionization time-of-flight mass spectrometry (MALDI-TOF MS). A total of 111 isolates, including 107 strains of common bacteria species and 4 strains of 3 yeast species, were tested by the traditional method and MALDI-TOF MS method(VITEK MS and Micro flex LT). Data obtained using MALDI-TOF MS were classified as Level 1 and Level 2 according to the confidence level of identification results from the VITEK MS ver. 1.0 database (VITEK MS) and MALDI Biotyper ver. 2.0 database (Microflex LT). The proportions of measured samples identified as Level 1 were 98.2% with the VITEK MS database and 87.4% with the MALDI Biotyper database. The concordance rates of the traditional method were 93.7% with the VITEK MS database and 82.0% with the MALDI Biotyper database. Identification results of five strains were mismatched between the traditional method and MALDI-TOF MS. Their ribosomal RNA sequences were identical to the results obtained from MALDI-TOF MS. We concluded that the performance of VITEK MS is superior to that of the traditional method and Microflex LT.

Aortic regurgitation caused by fibrous strand rupture in a fenestrated aortic valve

Fibrous strand rupture in a fenestrated aortic valve can cause acute severe aortic regurgitation. We report the case of a 56-year-old woman with severe aortic regurgitation. Transesophageal echocardiography showed an abnormal fibrous strand echo on the prolapsed left coronary cusp (LCC). The operative finding revealed one ruptured fibrous strand attached to the LCC at the commissure between the left and noncoronary cusps. Pathologic examination of the aortic valve revealed myxomatous degeneration.

[Role of the clinical laboratory for patients with massive transfusion undergoing elective surgery]

The microvascular bleeding resulting from the dilutional coagulopathy can occur when patients with massive blood loss are treated by infusing a lot of crystalloids, colloids, and red blood cell concentrates. For the management of dilutional coagulopathy and the appropriate replacement therapy of with coagulation factors and platelets, we usually monitor the patient's course of with platelet count, conventional coagulation tests such as the prothrombin time, the activated partial prothrombin time, and the fibrinogen concentration. The central clinical laboratory has a responsibility for an accurate and quick report of these test results of patients with massive transfusion. Furthermore, use of point care testing is of clinical value to fulfill a clinical demand in case with dilutional coagulopathy.

[Investigation of atherosclerosis using carotid ultrasonography]

Carotid ultrasonography is useful for patients in the early stage of atherosclerosis or with manifest vascular disease. We can assess the intima-media thickness (IMT), stenosis, and also elasticity of the carotid artery noninvasively. IMT is well-known as a strong predictor of future vascular events and a surrogate marker of atherosclerosis. We examined 353 consecutive subjects (coronary artery disease: n=92, cerebral vascular disease: n=62, peripheral arterial disease: n=104), regarding whether the accumulation of vascular diseases affects the IMT. The maximum IMT of the common carotid artery expanded with increasing numbers of vascular diseases (no vascular disease, 1.10 +/- 0.51; one vascular disease, 1.38 +/- 0.63; two vascular diseases, 1.69 +/- 0.65; three vascular diseases, 2.01 +/- 0.67 mm; p < 0.01, no vs. one vascular disease, one vs. two vascular diseases). The accumulation of vascular diseases, independent of the types of vascular lesion, accelerated carotid atherosclerosis. The stiffness parameter beta of the carotid artery was related to the brachial-to-ankle pulse wave velocity(baPWV) (n=38, r = 0.81, p < 0.0001). Stiffness parameter beta (10.95 +/- 2.8) and baPWV (1,549 +/- 179 cm/s) in the metabolic syndrome (MetS) group (n=18) was higher than in the preliminary MetS (n=12, 8.82 +/- 1.69, 1417 +/- 148 cm/s) and control (n=8, 7.90 +/- 1.78, 1357 +/- 171 cm/s) groups. The mean IMT of the common carotid artery was not different between the MetS and preliminary MetS groups. Morphological and functional changes in atherosclerosis can be evaluated employing carotid ultrasonography.

Determination by HPLC fluorescence analysis of the natural enantiomers of sex pheromones in the New World screwworm fly, Cochliomyia hominivorax

Bioassays of six racemic synthesized candidate sex pheromone compounds against male New World screwworm Cochliomyia hominivorax (Coquerel) flies showed that the most potent bioactivity was found with 6-acetoxy-19-methylnonacosane and 7-acetoxy-15-methylnonacosane compared with four other isomeric acetoxy nonacosanes and a larger aliphatic ketone. As all these methyl-branched compounds have two asymmetric carbons and four possible enantiomers, characterization of the natural enantiomers was essential. All four enantiomers for the two most bioactive isomers of the natural sex pheromone were synthesized for bioassay. Hydrolysis and derivatization of these enantiomers with different fluorescent reagents was followed by column-switched high-performance liquid chromatography. The use of two linked, reversed-phase columns of different polarity held at sub-ambient temperatures allowed good separation of each enantiomer. This analysis applied to natural material was successful, as (6R,19R)-6-acetoxy-19-methylnonanocosane, and (7R,15R)- and (7R,15S)-7-acetoxy-15-methylnonanocosane were detected in extracts of recently colonized female flies.

Brugada syndrome whose ST-segment changes were enhanced by antihistamines and antiallergenic drugs

We describe a case of Brugada syndrome, in which a coved type ST-segment elevation was enhanced by antihistamines and antiallergenic drugs. The patient had been treated with four kinds of antihistamines and antiallergenic drugs. The twelve-lead ECG exhibited a coved type ST-segment elevation in leads V(1) and V(2), and their enhancement was induced by pilsicainide. After discontinuing those drugs, the ST segment elevation in leads V(1) and V(2) became reduced. An ICD implantation was selected for the therapy since ventricular fibrillation was induced. Our report discusses the possible contribution of antihistamines and antiallergenic drugs to the Brugada type ST-segment changes.

Brugada syndrome case: difficult differentiation between a concealed form and tricyclic antidepressant-induced Brugada sign

We describe a case of Brugada syndrome, in which recurrent syncope with convulsive seizures was induced after antidepressant treatment. The patient had been treated with five kinds of psychotropic drugs. The twelve-lead ECG after the syncope exhibited an RSR'-pattern in the precordial leads, however, a coved type ST-segment elevation was induced by a pilsicainide test. Although ventricular fibrillation was not induced in the electrophysiologic study, an ICD implantation was considered as the recommended therapy since Brugada syndrome unmasked by antidepressants could not be ruled out. The possible contribution of antidepressants to Brugada type ST-segment changes is discussed.

Hyperinsulinemia is an independent predictor for complex atherosclerotic lesion of thoracic aorta in non-diabetic patients

OBJECTIVE

Hyperinsulinemia is a well known risk factor for cardiovascular event. However, it is not known whether hyperinsulinemia facilitates atherosclerotic complex lesions of aorta in non-diabetic patients. We investigated whether hyperinsulinemia is an independent marker of severity of atherosclerosis in thoracic aorta of non-diabetic patients using multiplane transesophageal echocardiography (TEE).

RESEARCH DESIGN AND METHODS

Non-diabetic 90 patients with cardiovascular disease underwent TEE, and were analyzed for plasma insulin levels of oral glucose tolerance test, conventional atherosclerotic risk factors and coronary angiographic features.

RESULTS

Thoracic aortic plaques were detected in 84 patients (93%). The complex atherosclerotic lesions were observed in 35 (39%) patients, most frequently at the part of aortic arch (p<0.005), showing the greatest atheroma score in thoracic aorta (p<0.05). Univariate analysis showed age, male gender, smoking, coronary artery disease, HDL-cholesterol, insulin levels in glucose tolerance test and homeostasis model assessment insulin resistance index (HOMA index) were found to be significant predictors of complex atherosclerotic lesions. Multivariate regression analysis revealed that HOMA index was an independent predictor of complex atherosclerotic lesions (odds ratio 1.93, p=0.006). There was a significant positive correlation between HOMA index and the atheroma score of thoracic aorta (p<0.001).

CONCLUSIONS

Hyperinsulinemia is an independent predictor of complex atherosclerotic lesions detected by TEE in the thoracic aorta of non-diabetic patients.

Brachyury homolog (HpTa) is involved in the formation of archenteron and secondary mesenchyme cell differentiation in the sea urchin embryo

Sea urchin Brachyury homolog (HpTa) is expressed exclusively in the vegetal plate and secondary mesenchyme cells in the embryos of sea urchin Hemicentrotus pulcherrimus. In order to gain insights into the role of HpTa during sea urchin development, we designed experiments to perturb the embryo by inducing ectopic overexpression of HpTa by injecting fertilized eggs with HpTa mRNA. The overexpression of HpTa resulted in suppression of the formation of vegetal plate and secondary mesenchyme cells. We assume that the interaction of HpTa with unknown factors is required for the activation of the HpTa target genes, and that the excess amount of HpTa proteins produced from injected HpTa mRNA depletes the co-factors. In consequence, the target genes of HpTa would be repressed by the overexpression of HpTa. We suggest that HpTa is involved in the formation of the vegetal plate and the differentiation of secondary mesenchyme cells.

Homocysteine promotes p38-dependent chemotaxis in bovine aortic smooth muscle cells

OBJECTIVE

Increased levels of homocysteine in the blood are a risk factor for atherosclerosis. The purpose of this study was to examine the effects of homocysteine on smooth muscle cell (SMC) migration and to determine whether p38 was involved in this process.

METHODS

The effect of 0.5 to 2.0 mmol/L d , l -homocysteine as a chemoattractant for SMCs was assayed with a modified Boyden chamber. To determine the functional role of p38 in SMC chemotaxis induced by d , l -homocysteine, we treated SMCs with a p38 inhibitor, SB203580, before the assay.

RESULTS

The number of migrated cells was increased 7.0 +/- 1.2-fold (n = 15; P < .001) by 2.0 mmol/L d , l -homocysteine. SB203580 partially prevented the migration of SMCs toward homocysteine. Preconditioning SMCs with 2.0 mmol/L d , l -homocysteine significantly enhanced chemotaxis toward 10% fetal bovine serum compared with nonconditioned control SMCs (28.9 +/- 3.3-fold vs 15.6 +/- 2.8-fold; P < .05). There was a fourfold p38 activation after exposure of SMCs to 2.0 mmol/L d , l -homocysteine by immunoblot.

CONCLUSIONS

These results suggest that homocysteine not only is a chemoattractant for SMC but can also enhance SMC chemotactic potential. The mechanism of these effects may involve p38 activation.

CLINICAL RELEVANCE

This study demonstrates that homocysteine can promote chemotaxis of SMCs through a p38-dependent pathway. To our knowledge, this is the first report that homocysteine may influence SMC chemotaxis. It may be an important mechanism for homocysteine-induced atherogenesis, because the migration of SMCs from the media is believed to play a critical role in progressive intimal thickening. Although homocysteine promotes atherogenesis and thrombosis by a variety of mechanisms, the effects of homocysteine on SMC proliferation and migration might be critical elements that may have potential therapeutic implications, because selective blockade of the p38 pathway is feasible.

Sea urchin insulator protects lentiviral vector from silencing by maintaining active chromatin structure

Suppressed expression of transgenes in vivo is the major obstacle in the gene therapy. For the long-term expression, we utilized a chromatin insulator from sea urchin arylsulfatase (Ars) gene locus (Ars insulator, ArsI), which has been shown to epigenetically regulate gene expression across species. ArsI was able to prevent silencing of the transgene in a myeloid cell line, HL-60, and a murine embryonic stem cell line, CCE, in an orientation-dependent manner, but not in Huh-7, K562 and MCF-7 cells, indicating that the effect of ArsI on gene silencing was cell type dependent. Although anti-silencing effect of ArsI was almost equivalent to that of chicken beta-globin insulator, incorporation of ArsI into lentiviral vector had little effect on the virus titer compared with chicken beta-globin insulator. Clonal analysis of transduced HL-60 cells revealed that ArsI protects the lentiviral vector from position effects regardless of its orientation. Furthermore, chromatin immunoprecipitation assays revealed that a high acetylation level was observed in the promoter of the insulated vector, whereas that of ArsI was independent of its anti-silencing capacity. In addition to it having little deteriorative effect on the virus titer, the identified anti-silencing effect of ArsI suggested its possibility for application in gene therapy.

High pressure nmr study of dihydrofolate reductase from a deep-sea bacterium Moritella profunda

We have investigated the effect of pressure and temperature on the structural and thermodynamic stability of a protein dihydrofolate reductase from a deep-sea bacterium Moritella profunda in its folate-bound form in the pressure range between 3 and 375 MPa and the temperature range between -5 and 30 degrees C. The on-line cell variable pressure 1H NMR spectroscopy has been used to analyze the chemical shift and signal intensity in one-dimensional 1H NMR spectra. Thermodynamic analysis based on signal intensities from protons in the core part indicates that the thermodynamic stability of Moritella profunda DHFR is relatively low over the temperature range between -5 and 30 degrees C (deltaG0=15.8 +/- 4.1 kJ/mol at 15 degrees C), but is well adapted to the living environment of the bacterium (2 degrees C and 28 MPa), with the maximum stability around 5 degrees C (at 0.1 MPa) and a relatively small volume change upon unfolding (deltaV= 66 +/- 19 ml/mol). Despite the relatively low overall stability, the conformation in the core part of the folded protein remains intact up to approximately 200 MPa, showing marked stability of the core of this protein.

Native-like tertiary structure formation in the alpha-domain of a hen lysozyme two-disulfide variant

Structure formation in two species of the two-disulfide variant of hen lysozyme was investigated by means of CD spectroscopy, disulfide exchange measurement, and 1H-NMR spectroscopy. One species, 2SS [6-127, 30-115], which contained the two disulfide bonds found in the alpha-domain of authentic lysozyme, had amounts of secondary and tertiary structures, and bacteriolytic activity comparable to those of authentic lysozyme, and showed a cooperative thermal unfolding. By contrast, the other species, 2SS [64-80, 76-94], which contained the beta-domain disulfide bond as well as the inter-domain one, had a limited amount of secondary structure and little tertiary structure. Disulfide-exchange did not occur for 2SS [6-127, 30-115], whereas it occurred for 2SS [64-80, 76-94], indicating that the protein main-chain fold coupled with the formation of two disulfide bonds is relatively stable for the former variant, while unstable for the latter. 1H-NMR spectra of 2SS [6-127, 30-115] showed that native-like local environment is present within the region that corresponds to the alpha-domain, while it is absent within the region that corresponds to the beta or inter-domain. These results indicate that the alpha-domain of hen lysozyme can be an independent folding domain at equilibrium. Although the bipartite nature in the structure formation of hen lysozyme is similar to that reported for alpha-lactalbumin, differences exist between the disulfide-intermediates of the two proteins in terms of the structural domain that accomplishes tertiary structure.

Two folded conformers of ubiquitin revealed by high-pressure NMR

High-pressure 15N/1H two-dimensional NMR spectroscopy has been utilized to study conformational fluctuation of a 76-residue protein ubiquitin at pH 4.5 at 20 degrees C. The on-line variable pressure cell technique is used in conjunction with a high-field NMR spectrometer operating at 750 MHz for 1H in the pressure range between 30 and 3500 bar. Large, continuous and reversible pressure-induced 1H and 15N chemical shifts were observed for 68 backbone amide groups, including the 7.52 ppm 15N shift of Val70 at 3500 bar, indicating a large-scale conformational change of ubiquitin with pressure. On the basis of the analysis of sigmoid-shaped pressure shifts, we conclude that ubiquitin exists as an equilibrium mixture of two major folded conformers mutually converting at a rate exceeding approximately 10(4) s(-1) at 20 degrees C at 2000 bar. The second conformer exists at a population of approximately 15% (DeltaG(0) = 4.2 kJ/mol) and is characterized with a significantly smaller partial molar volume (DeltaV(0) = -24 mL/mol) than that of the well-known basic native conformer. The analysis of 1H and 15N pressure shifts of individual amide groups indicates that the second conformer has a loosened core structure with weakened hydrogen bonds in the five-stranded beta-sheet. Furthermore, hydrogen bonds of residues 67-72 belonging to beta5 are substantially weakened or partially broken, giving increased freedom of motion for the C-terminal segment. The latter is confirmed by the significant decrease in 15N[1H] nuclear Overhauser effect for residues beyond 70 at high pressure. Since the C-terminal carboxyl group constitutes the reactive site for producing a multi-ubiquitin structure, the finding of the second folded conformer with a substantially altered conformation and mobility in the C-terminal region will shed new light on the reaction mechanism of ubiquitin.

High-pressure NMR study of the complex of a GTPase Rap1A with its effector RalGDS. A conformational switch in RalGDS revealed from non-linear pressure shifts

Unusually large non-linear 1H and 15N nuclear magnetic resonance chemical shifts against pressure have been detected for individual amide groups of the Ras-binding domain of Ral guanine dissociation stimulator (GDS). The non-linear response is largest in the region of the protein remote from the Rap1A-binding site, which increases by about two-fold by the complex formation with its effector protein Rap1A. The unusual non-linearity is explained by the increasing population of another conformer (N'), lying energetically above the basic native conformer (N), at higher pressure. It is considered likely that the conformational change from N to N' in the Ras-binding domain of RalGDS works as a switch to transmit the effector signal further to molecules of different RalGDS-dependent signaling pathways.

Filling a cavity dramatically increases pressure stability of the c-Myb R2 subdomain

Cavities or packing defects in proteins may generally be related with the dynamics and function of a protein. In the c-Myb R2 subdomain, its single cavity has been shown to be crucial for its DNA recognition. Cavities are also considered important in determining the pressure stability of a protein. In the present work, high-pressure proton nuclear magnetic resonance ((1)H NMR) spectroscopy at 750 MHz is used to study the effect of a cavity-filling mutation (V103L) on the stability of the c-Myb R2 subdomain in the pressure range between 1 and 3,700 bar at 5 degrees C. A dramatic increase in the pressure stability of the c-Myb R2 subdomain is attained, from which we estimate the cavity size to be 35.3 A(3), in good agreement with literature values. We also evaluated the increase in thermodynamic stability DeltaG(0)(1bar) from 5.35 kJ/mol to 7.34 kJ/mol by the mutation, giving a clear example of the effect of a cavity on the global stability of a globular protein.

1H NMR application for characterizing water-soluble organic compounds in urban atmospheric particles

Water-soluble organic compounds (WSOC) in urban atmospheric particles separated by particle size were analyzed by 1H NMR. This is the first utilization of 1H NMR for characterizing WSOC in atmospheric particles. The WSOC dissolved in D2O were analyzed without a separation procedure. Twelve low molecular weight WSOC could be identified and their atmospheric concentrations determined. One of these, monomethyl hydrogen sulfate (MHS), was first detected in an urban area where no oil or coal power plant existed. Methanesulfonic acid (MSA) and hydroxymethanesulfonic acid (HMSA) were detected as major organosulfur compounds. Relatively high concentrations of these low molecular weight WSOC were observed in the particle diameter range of 0.43-1.1 microns. Many complex signals at 3-4 ppm in the NMR spectrum were seen only for the coarse particle samples (1.1 microns < particle diameter). Mannitol was believed to exist in the coarse particles as a major polyol corresponding to these signals. On the other hand, a large broad signal, observed at 2.5-3 ppm, was mostly present in the fine particles. Finally, it was believed that a major part of the WSOC in urban atmospheric fine particles is attributed to ketocarboxylic acids, ketodicarboxylic acids, and dicarboxylic acids.

An insulator element from the sea urchin Hemicentrotus pulcherrimus suppresses variation in transgene expression in cultured tobacco cells

Specialized DNA sequences known as insulators protect genes from both the positive and negative influences of nearby chromatin. Many insulators have been identified in various species; however, few function in multiple species. We have shown that an insulator from the Ars (arylsulfatase) gene of the sea urchin Hemicentrotus pulcherrimus functions in plant cells. Normally, expression of an introduced chimeric GUS gene is inactivated in approximately 30% of transformed tobacco BY2 clones. Transgenes containing the Ars insulator, however, were expressed in all transformed tobacco BY2 cells. The insulator did not affect the copy number, the chromosomal position of transgene integration or maximum expression levels. These results suggest that the insulator functions to suppress the variation normally associated with transgene expression in tobacco BY2 cells.

Response of native and denatured hen lysozyme to high pressure studied by (15)N/(1)H NMR spectroscopy

High-pressure (15)N/(1)H NMR techniques were used to characterize the conformational fluctuations of hen lysozyme, in its native state and when denatured in 8 M urea, over the pressure range 30--2000 bar. Most (1)H and (15)N signals of native lysozyme show reversible shifts to low field with increasing pressure, the average pressure shifts being 0.069 +/- 0.101 p.p.m. ((1)H) and 0.51 +/- 0.36 p.p.m. ((15)N). The shifts indicate that the hydrogen bonds formed to carbonyl groups or water molecules by the backbone amides are, on average, shortened by approximately 0.02 A as a result of pressure. In native lysozyme, six residues in the beta domain or at the alpha/beta domain interface have anomalously large nonlinear (15)N and (1)H chemical-shift changes. All these residues lie close to water-containing cavities, suggesting that there are conformational changes involving these cavities, or the water molecules within them, at high pressure. The pressure-induced (1)H and (15)N shifts for lysozyme denatured in 8 M urea are much more uniform than those for native lysozyme, with average backbone amide shifts of 0.081 +/- 0.029 p.p.m. ((1)H) and 0.57 +/- 0.14 p.p.m. ((15)N). The results show that overall there are no significant variations in the local conformational properties of denatured lysozyme with pressure, although larger shifts in the vicinity of a persistent hydrophobic cluster indicate that interactions in this part of the sequence may rearrange. NMR diffusion measurements demonstrate that the effective hydrodynamic radius of denatured lysozyme, and hence the global properties of the denatured ensemble, do not change detectably at high pressure.

TAG-1-deficient mice have marked elevation of adenosine A1 receptors in the hippocampus

TAG-1 is a neural recognition molecule in the immunoglobulin superfamily that is predominantly expressed in the developing brain. Several lines of evidence suggest that TAG-1 is involved in the outgrowth, guidance, and fasciculation of neurites. To directly assess the function of TAG-1 in vivo, we have generated mice with a deletion in the gene encoding TAG-1 using homologous recombination in embryonic stem cells. Gross morphological analysis of the cerebellum, the spinal cord, and the hippocampus appeared normal in TAG-1-deficient mice. However, TAG-1 (-/-) mice showed the upregulation of the adenosine A1 receptors determined by [(3)H]cyclopentyl-1,3-dipropylxanthine in the hippocampus, and their greater sensitivity to convulsant stimuli than that in TAG-1 (+/+) mice. We suspect that the subtle changes in neural plasticity induced by TAG-1 deficiency during development cause the selective vulnerability of specific brain regions and the epileptogenicity in TAG-1 (-/-) mice.