[Gastric metastasis of breast cancer treated as primary gastric cancer due to difficulty in differentiating primary and metastatic cancer:a case report]

A female patient in her 50s who underwent chemotherapy for left primary breast cancer presented with cancerous pleurisy and disseminated intravascular coagulation. Esophagogastroduodenoscopy and liver biopsy revealed gastric and liver cancer. Distinguishing between primary and metastatic cancer by pathological findings is difficult using hematoxylin and eosin staining. We diagnosed and treated simultaneous primary breast cancer (ER-positive) and gastric cancer with liver metastasis (ER-negative), based on differences in estrogen receptor expression. The patient lived for 10 months with chemotherapy. After death, an autopsy was performed because the endoscopic results were atypical for primary gastric cancer, and additional immunohistochemical studies indicated gastric metastasis of breast cancer.

Comparison of the long-term outcomes of EUS-guided gallbladder drainage and endoscopic transpapillary gallbladder drainage for calculous cholecystitis in poor surgical candidates: a multicenter propensity score-matched analysis

BACKGROUND AND AIMS

Although long-term stent placement using endoscopic transpapillary gallbladder drainage (ETGBD) and EUS-guided gallbladder drainage (EUS-GBD) reportedly reduces cholecystitis recurrence, comparative evidence of their safety and efficacy is scarce. This study aimed to examine and compare the long-term utility of EUS-GBD versus that of ETGBD in poor surgical candidates.

METHODS

A total of 379 high-risk surgical patients with acute calculous cholecystitis met the eligibility criteria for enrollment in this study. The technical success and adverse events (AEs) were compared between the EUS-GBD and ETGBD groups, and propensity score matching was performed to adjust for differences between the groups. Both groups underwent plastic stent placement, and scheduled stent exchange and removal were not performed in either group.

RESULTS

The technical success rate of EUS-GBD was significantly higher than that of ETGBD (96.7% vs 78.9%, P < .001), whereas the early AE rate did not differ significantly between the 2 methods (7.8% vs 8.9%, P = 1.000). The rate of recurrent cholecystitis did not differ significantly (3.8% vs 3.0%, P = 1.000), but the rate of symptomatic late AEs, in addition to cholecystitis, was significantly lower with EUS-GBD than with ETGBD (1.3% vs 13.4%, P = .006). Consequently, the overall late AE rate was significantly lower with EUS-GBD (5.0% vs 16.4%, P = .029). Multivariate analysis revealed that EUS-GBD was associated with a significantly longer time to late AE (hazard ratio, .26; 95% confidence interval, .10-.67; P = .005).

CONCLUSIONS

Long-term stent placement via EUS-GBD is a promising potential option for limiting late AEs, including recurrence, in poor surgical candidates with calculous cholecystitis.

[A rare case of hepatosplenic cat scratch disease]

A female patient in her 60s, treated with oral corticosteroids for scleroderma diagnosed 11 years ago, visited our hospital complaining of a persistent fever and liver dysfunction. She was treated with antibiotics, but her fever continued. Abdominal ultrasonography revealed multiple hypoechoic splenic masses. Splenic masses revealed multiple masses with no contrast effect in arterial and portal phases and nuclear in equilibrium phase by contrast computed tomography study, as well as hyperintensity masses with low signal areas in magnetic resonance imaging T2-weighted images. Liver tissue was obtained by percutaneous liver biopsy, and histological findings showed epithelioid cell granulomas without tumor cells. Further interview and physical examination revealed scratch scars from domestic cats and left axillary lymph node swelling. Hence, a cat scratch disease was suspected. She was diagnosed with cat scratch disease by serum indirect immunofluorescence. Her fever was resolved with minocycline administration. Therefore, persistent fever with splenic masses should be suspected of hepatosplenic cat scratch disease.

One-step versus two-step distal self-expandable metal stent placement: A multicenter prospective randomized trial

BACKGROUND AND AIM

Two methods of transpapillary covered self-expandable metal stent (SEMS) placement are used for distal malignant biliary obstruction (MBO): after initial drainage by plastic stent (two-step method) and without previous drainage (one-step method).

METHODS

In total, 90 patients with unresectable pancreatic cancer and distal MBO were enrolled in this prospective multicenter randomized study and allocated to one-step (n = 45) and two-step (n = 45) groups. The main outcome was the time to recurrent biliary obstruction (TRBO). Secondary outcomes were the rates of early and late adverse events, survival time, the time required for bilirubin level reduction, and cost-effectiveness.

RESULTS

The median TRBO did not differ significantly between the one-step and two-step groups (not available vs 314 days, P = 0.134). SEMS migration occurred significantly more frequently in the two-step group (14.3% vs 0%, P = 0.026). No significant difference was observed between groups in early (7.3% vs 14.3%, P = 0.483) or late (12.2% and 11.9%, P = 1) adverse events other than RBO, survival time (P = 0.104), or the median number of days required to reach a bilirubin level considered to be acceptable for chemotherapy administration (<3 mg/dL; P = 0.881). The total costs of stent placement and reintervention were significantly lower in the one-step SEMS group (3347 vs 5465 US dollars, P < 0.001).

CONCLUSIONS

The superiority of TRBO with two-step SEMS placement was not demonstrated. One-step SEMS placement might be a promising method from the viewpoints of cost-effectiveness and less invasiveness (UMIN-CTR clinical trial registration number: UMIN000016010).

Multi-center study of endoscopic revision after side-by-side metal stent placement for malignant hilar biliary obstruction

BACKGROUND

The recent development of ultra-thin delivery systems, which enable simultaneous insertion of two metal stents, has encouraged wider adoption of side-by-side (SBS) stent placement for malignant hilar biliary obstruction (MHBO). However, the management of stent occlusion after SBS placement has not been well-characterized. This study aimed to examine the outcomes of endoscopic reintervention (E-RI) after SBS placement in patients with MHBO.

METHODS

Sixty-seven patients who underwent E-RI for stent occlusion after SBS placement between 2013 and 2020 at three tertiary-care referral centers were investigated. We evaluated the technical success, clinical success, recurrent biliary obstruction (RBO), and adverse events other than RBO rates associated with E-RI. Furthermore, the factors associated with successful E-RI were also evaluated.

RESULTS

The technical success and clinical success rates were 79.1% (53/67) and 76.1% (51/67), respectively. Early adverse events other than RBO occurred in 4.5% (3/67) and late events in 3.9% (2/51). The RBO rate after E-RI was 52.9% (27/51), and the median time to RBO after E-RI was 85 days. Common bile duct (CBD) diameter (odds ratio 2.62; 95% confidence interval, 1.37-5.01; P = 0.003) and metastatic disease (odds ratio, 0.11; 95% confidence interval, 0.02-0.64; P = 0.015) were independently correlated with E-RI success in the multivariate analysis.

CONCLUSIONS

This study demonstrated that E-RI after SBS placement is technically feasible and safe, but the success rate was significantly lower in patients with narrow CBDs and metastatic diseases. These factors may be useful for the selection of the initial stenting method.

[A case of adult intussusception associated with Escherichia coli enterocolitis]

A 38-year-old man visited our hospital with a complaint of diarrhea and abdominal pain. Contrast-enhanced computed tomography showed that the ileocecal site was intussuscepted to the transverse colon without ischemia. After we reduced intussusception with an enema using a water-soluble contrast agent, his abdominal pain disappeared. Colonoscopy was performed immediately after reduction and showed erosion and edema at the ileocecal site without tumor. The stool culture at admission revealed verotoxin 1 producing Escherichia coli O-26;therefore, we established a diagnosis of intussusception associated with Escherichia coli enterocolitis. Bacterial enteritis should be considered as a potential cause in adult patients with intussusception.

Efficacy of Contrast-enhanced Computed Tomography for the Treatment Strategy of Colonic Diverticular Bleeding

OBJECTIVE

Diverticular bleeding is the most common cause of acute lower gastrointestinal bleeding, and its incidence has recently increased. However, the treatment strategy of diverticular bleeding has not yet been established. The aim of the study was to investigate the efficacy of contrast-enhanced computed tomography (CECT) to determine the indication for urgent colonoscopy to achieve hemostasis.

METHODS

A total of 124 patients diagnosed with diverticular bleeding between 2012 and 2013 in our hospital were analyzed. The clinical behavior, factors related to detecting bleeding diverticula, and risk factors for early rebleeding of diverticular bleeding were evaluated.

RESULTS

Clinical behavior: Bleeding diverticula were identified in 23 of 124 (19%) patients and most of them (16/23; 70%) were located in the ascending colon. Hemostasis was achieved in all 23 cases, however, six (26%) developed early rebleeding. Factors for detecting bleeding diverticula: In patients in whom extravasation was detected using CECT, the endoscopic detection rate of bleeding diverticula was 60% (12/20), while bleeding diverticula were detected in only 31% (11/35) of patients in whom extravasation was not detected using CECT (p<0.05). The interval between the first hematochezia and colonoscopy in which the bleeding point was detected by colonoscopy (median 23.5 hours) was shorter than that in which bleeding diverticula were not detected (median 43.6 hours) (p<0.01). Risk factors for short term rebleeding: Using a univariate analysis, atherosclerotic comorbidity, anti-inflammatory drugs including low-dose aspirin, antithrombotic agents, vital signs on admission, hemoglobin level on hospitalization, and extravasation on CECT were not found to be significant risk factors.

CONCLUSION

The finding of extravasation on CECT is the most important factor for identifying and treating bleeding diverticula by colonoscopy. In such cases, urgent colonoscopy is recommended.

From 'culture of dehumanization of childbirth' to 'childbirth as a transformative experience': changes in five municipalities in north-east Brazil

Brazil has become a country known as having one of the most extreme examples of the consequences of the hospital-based medicalization of delivery care, while a model of humanization of birth was developed in the State of Ceará in the 1970s. The Government of Japan, through the Japanese International Cooperation Agency (JICA), collaborated with the Federal Ministry of Health of Brazil and the Government of the State of Ceará, in implementing the Maternal and Child Health Improvement Project in north-east Brazil (1996-2001). This project focused on 'humanization of childbirth', with training based intervention activities. Behavioral changes among health professionals who received the project's participatory type of training were described using rapid anthropological assessment procedure (RAP) survey results. Changes from 'a culture of dehumanization of childbirth' to 'childbirth as a transformative experience' were observed.

A novel disaccharide substrate having 1,2-oxazoline moiety for detection of transglycosylating activity of endoglycosidases

A disaccharide substrate of Manbeta1-4GlcNAc-oxazoline 2 was designed and synthesized as a novel probe for detection of the transglycosylating activity of endoglycosidases. A regio- and stereoselective transglycosylation reaction of 2 to GlcNAcbeta1-O-pNP or Dns-Asn(GlcNAc)-OH catalyzed by endo-beta-N-acetylglucosaminidase from Mucor hiemalis (Endo-M) and endo-beta-N-acetylglucosaminidase from Arthrobacter protophormiae (Endo-A) has been demonstrated for the first time, resulting in the core trisaccharide derivative Manbeta1-4GlcNAcbeta1-4GlcNAcbeta1-O-pNP 8 (or -(Dns)Asn-OH). Interestingly, the transglycosylation proceeds irreversibly; the resulting trisaccharide 8 was not hydrolyzed by Endo-M and Endo-A. Based on these results, a new mechanism including an oxazolinium ion intermediate has been proposed for the endoglycosidase-catalyzed hydrolysis or transglycosylation.

Chemo-enzymatic synthesis of a bioactive peptide containing a glutamine-linked oligosaccharide and its characterization

A bioactive peptide containing a glutamine-linked oligosaccharide was chemo-enzymatically synthesized by use of the solid-phase method of peptide synthesis and the transglycosylation activity of endo-beta-N-acetylglucosaminidase. Substance P, a neuropeptide, is an undecapeptide containing two L-glutamine residues. A substance P derivative with an N-acetyl-D-glucosamine residue attached to the fifth or sixth L-glutamine residue from the N-terminal region was chemically synthesized. A sialo complex-type oligosaccharide derived from a glycopeptide of hen egg yolk was added to the N-acetyl-D-glucosamine moiety of the substance P derivative using the transglycosylation activity of endo-beta-N-acetylglucosaminidase from Mucor hiemalis, and a substance P derivative with a sialo complex-type oligosaccharide attached to the L-glutamine residue was synthesized. This glycosylated substance P was biologically active, although the activity was rather low, and stable against peptidase digestion. The oligosaccharide moiety attached to the L-glutamine residue of the peptide was not liberated by peptide-N(4)-(N-acetyl-beta-D-glucosaminyl) asparagine amidase F.

Effect of carbohydrate structure on biological activity of artificially N-glycosylated eel calcitonin

To reveal the function of the carbohydrate portion of glycopeptides and glycoproteins, we chemo-enzymatically synthesized artificially N-glycosylated derivatives of eel calcitonin and studied their three-dimensional structure and biological activity. The CD and NMR spectra in trifluoroethanol-H(2)O solution showed that the glycosylation did not change the three-dimensional structure. All the derivatives retained the strong in vivo hypocalcemic activity of calcitonin. However, the relative activity was dependent on the structure of the attached carbohydrate. The single GlcNAc attachment best enhanced the activity, while larger carbohydrates decreased the activity. This relative activity order of compounds could be partly explained by their calcitonin-receptor binding affinity, though the affinity of the GlcNAc derivative did not exceed that of calcitonin. The enhanced hypocalcemic activity of the GlcNAc derivative was explained by its altered biodistribution. The GlcNAc attachment caused calcitonin to escape from the trap at the liver during the early circulation. Thus, the glycosylation was shown to modulate the biological activity of calcitonin depending on the carbohydrate structure without a change in the peptide backbone conformation.

Transforming growth factor-beta secreted from CD4(+) T cells ameliorates antigen-induced eosinophilic inflammation. A novel high-dose tolerance in the trachea

The induction of peripheral tolerance is one of the feasible approaches for the control of autoimmunities and allergies. Tolerance induction in the intestine has been studied extensively and therapeutic applications to autoimmunities are in progress, whereas tolerance in the respiratory tract is poorly investigated. We examined the immunoregulatory mechanisms for evading exaggerated inflammatory responses in the murine airway mucosa. Administration of an optimal dose of ovalbumin (OVA) to the trachea elicited eosinophilic inflammation in the trachea of OVA/aluminum hydroxide-sensitized BALB/c mice, whereas higher doses were unable to do so. This failure paralleled the downregulation of interleukin-4 production by mediastinal lymph node (LN) T cells. This high-dose tolerance was attributable to the mechanisms of antigen (Ag)-specific suppression, because the adoptive transfer of CD4(+) LN T cells from the OVA-tolerant mice inhibited the OVA-specific, but not irrelevant Ag KLH-specific, eosinophilic responses. The inhibitory effects were neutralized by the intratracheal administration of anti-transforming growth factor (TGF)-beta, but not that of anti-interferon (IFN)-gamma, monoclonal antibodies, indicating that the high-dose tolerance was mediated by secreted TGF-beta, but not by the dominance of transferred T helper (Th)1 cells over Th2 cells. The pivotal role of TGF-beta was reinforced by the finding that the LN cells from the OVA-tolerant mice produced TGF-beta in response to the in vitro Ag stimulation. These results demonstrate a novel regulatory mechanism in the airway: that TGF-beta secreted by T cells plays an important role in the downmodulation of the immune responses to high doses of Ag which might otherwise induce deleterious inflammation in the airway mucosal tissues.

Effects of glycosylation on the structure and dynamics of eel calcitonin in micelles and lipid bilayers determined by nuclear magnetic resonance spectroscopy

The three-dimensional structures of eel calcitonin (CT) and two glycosylated CT derivatives, [Asn(GlcNAc)3]-CT (CT-GlcNAc) and [Asn(Man6-GlcNAc2)3]-CT (CT-M6), in micelles were determined by solution NMR spectroscopy. The topologies of these peptides associated with oriented lipid bilayers were determined with solid-state NMR. All of the peptides were found to have an identical conformation in micelles characterized by an amphipathic alpha-helix consisting of residues Ser5 through Leu19 followed by an unstructured region at the C-terminus. The overall conformation of the peptide moiety was not affected by the glycosylation. Nevertheless, comparison of the relative exchange rates of the Leu12 amide proton might suggest the possibility that fluctuations of the alpha-helix are reduced by glycosylation. The presence of NOEs between the carbohydrate and the peptide moieties of CT-GlcNAc and CT-M6 and the amide proton chemical shift data suggested that the carbohydrate interacted with the peptide, and this might account for the conformational stabilization of the alpha-helix. Both the unmodified CT and the glycosylated CT were found to have orientations with their helix axes parallel to the plane of the lipid bilayers by solid-state NMR spectroscopy.

Ovalbumin (OVA) and Mycobacterium tuberculosis bacilli cooperatively polarize anti-OVA T-helper (Th) cells toward a Th1-dominant phenotype and ameliorate murine tracheal eosinophilia

A recent increase in allergic disorders has coincided with a decrease in infections, including tuberculosis. Although an inverse association between tuberculin responses and atopic disorders was reported, it was not known how T-helper (Th)1-biased immune responses to Mycobacterium tuberculosis influenced Th2-dominant responses to allergens. We examined whether M. tuberculosis could modulate ovalbumin (OVA)-induced eosinophilic inflammation in the murine trachea in a manner that transcended the barrier of antigen specificity. We found that CD4(+) T cells primed with OVA in complete Freund's adjuvant (CFA) inhibited OVA-induced tracheal eosinophilia through interferon (IFN)-gamma secretion. Immunization with an irrelevant antigen in CFA or with OVA in incomplete Freund's adjuvant failed to induce suppressor cells. In vitro experiments confirmed that both M. tuberculosis and OVA (as opposed to either one alone) were necessary to evoke polarized development toward a Th1-like phenotype through interleukin-12 secretion. These results indicate that exposure to an allergen along with M. tuberculosis switches development of allergen-specific T cells toward a Th1 phenotype, which, in turn, downregulates allergic manifestations in an antigen-specific manner. The possible implications of these results are discussed in the context of the causal relationship between a decrease in tuberculosis and an increase in allergic disorders.

[Comparison of CRH test and ACTH test in patients with bronchial asthma]

Although glucocorticoid is the most effective agent for bronchial asthma, its systemic administration leads to suppression of adrenocortical function. Rapid ACTH test has been performed for assessing the function of the hypothalamic-pituitary-adrenocortical (HPA) system of asthmatics. Recently human corticotropin-releasing hormone (CRH) has been chemically synthesized. In order to evaluate clinical usefulness of CRH, we compared CRH test with ACTH test in 17 patients with bronchial asthma (3 patients out of them concurrently receiving prednisolone 5-10 mg/day). Both tests were carried out within 2 weeks after 6 month treatment with fluticasone propionate (800 micrograms/day) inhaled via pMDI. There is no significant difference between results obtained from the both tests. Thus, dividing subjects into high and low responders based on an extent of increases in plasma ACTH levels after the CRH injection, we found a significant difference in maximal plasma concentrations of cortisol between after CRH and ACTH injections in the low responders. Therefore, in some patients, CRH test provides more accurate assessment of the function of HPA system than ACTH test.

Chemo-enzymatic synthesis of a calcitonin derivative containing a high-mannose type oligosaccharide by endo-β-N-Acetylglucosaminidase from Arthrobacter protophormiae

Chemo-enzymatic addition of a high-mannose type oligosaccharide to eel calcitonin (CT), a calcium-regulating hormone, was examined. The endo-beta-N-acetylglucosaminidase from Arthrobacter protophormiae (Endo-A) transglycosylated the Man(6)-GlcNAc moiety from an ovalbumin-derived high-mannose type glycosyl asparagine, Asn(Man(6)-GlcNAc(2))-OH, to a calcitonin derivative, [Asn(GlcNAc)(3)]-CT, in which the N-acetyl-d-glucosamine (GlcNAc) is attached to the third l-asparagine (Asn) residue of the peptide, and a calcitonin derivative containing a high-mannose type oligosaccharide, [Asn(Man(6)-GlcNAc(2))(3)]-CT, was synthesized. The optimal reaction conditions for the synthesis of [Asn(Man(6)-GlcNAc(2))(3)]-CT from Asn(Man(6)-GlcNAc(2))-OH and [Asn(GlcNAc)(3)]-CT catalyzed by Endo-A were examined. The transglycosylation yield relative to the concentration of the [Asn(GlcNAc)(3)]-CT added was 32.7%, and 4.42 mg of [Asn(Man(6)-GlcNAc(2))(3)]-CT was prepared.

Chemo-enzymatic synthesis of calcitonin derivatives containing N-linked oligosaccharides

Eel calcitonin derivatives containing various N-linked oligosaccharides were chemo-enzymatically synthesized by the transglycosylation reaction of Mucor hiemalis endo-beta-N-acetylglucosaminidase (Endo-M) to a glycosylated calcitonin derivative [Asn(GlcNac)3]-CT in which N-acetyl-D-glycosamine (GlcNAc) is attached to the L-asparagine (Asn) residue of the peptide.

Chemoenzymatic synthesis of a novel glycopeptide using a microbial endoglycosidase

The chemoenzymatic synthesis of a glycopeptide by chemical synthesis of N-acetylglucosaminyl peptide and enzymatic transfer of an oligosaccharide is described. We synthesized glycosylated Peptide T which blocks infection of human T cells by human immunodeficiency virus. The first step of the chemoenzymatic method is the solid-phase chemical synthesis of N-acetylglucosaminyl Peptide T (Ala-Ser-Thr-Thr-Thr-Asn(GlcNAc)-Tyr-Thr) with an N-acetylglucosamine moiety bound to the asparaginyl residue by a solid-phase method. This product was prepared in high yield by the dimethylphosphinothioic mixed anhydride method without protecting the hydroxyl functions of the sugar moiety using Fmoc-N-acetylglucosaminyl asparagine instead of Fmoc-asparagine. The second step was transglycosylation of complex type oligosaccharide to N-acetylglucosaminyl Peptide T by a microbial endoglycosidase. The endo-beta-N-acetylglucosaminidase of Mucor hiemalis transfer the oligosaccharide of human transferrin glycopeptide to N-acetylglucosaminyl Peptide T. The transglycosylation product was confirmed to be the glycosylated Peptide T with a sialo biantennary complex type oligosaccharide by mass spectrometry. The glycosylated Peptide T was highly stable against proteolysis in comparison to native Peptide T and N-acetylglucosaminyl Peptide T.

TGF-beta induced by oral tolerance ameliorates experimental tracheal eosinophilia

Induction of peripheral tolerance is one of the feasible approaches for the control of autoimmunities and allergies. Therapeutic applications of oral tolerance to autoimmunities are in progress both experimentally and clinically, while those to allergies have been poorly investigated. We examined the induction of CD4+ T cells with suppressive properties by oral tolerance and the mechanism by which these cells down-regulated Ag-induced eosinophilia in the trachea. Feeding of mice transgenic for anti-OVA TCR with high doses of OVA inhibited the airway eosinophilic inflammation induced by the intratracheally administered Ag. This inhibition reflected the mechanism of active suppression, since the inhibitory effect was adoptively transferred by splenic CD4+ T cells from the transgenic mice fed with high doses of OVA. The Ag specificity of the suppressor T cells was documented by the failure of spleen cells from mice that were orally tolerant of OVA to suppress irrelevant Ag, KLH-specific airway eosinophilic inflammation. The suppressive effect of the transferred T cells on eosinophil recruitment was neutralized by anti-TGF-beta mAb, but not anti-IFN-gamma mAb, indicating that the suppression is due to the inhibitory effect by secreted TGF-beta, but not to the dominance of the transferred Th1 cells over Th2 cells. This is the first study to reveal a link between oral tolerance and the regulation of Th2-mediated experimental tracheal eosinophilia through TGF-beta. Our experimental model suggests possible therapeutic applications of oral tolerance for the treatment of allergic disorders such as bronchial asthma.

TGF-beta induced by oral tolerance ameliorates experimental tracheal eosinophilia

Induction of peripheral tolerance is one of the feasible approaches for the control of autoimmunities and allergies. Therapeutic applications of oral tolerance to autoimmunities are in progress both experimentally and clinically, while those to allergies have been poorly investigated. We examined the induction of CD4+ T cells with suppressive properties by oral tolerance and the mechanism by which these cells down-regulated Ag-induced eosinophilia in the trachea. Feeding of mice transgenic for anti-OVA TCR with high doses of OVA inhibited the airway eosinophilic inflammation induced by the intratracheally administered Ag. This inhibition reflected the mechanism of active suppression, since the inhibitory effect was adoptively transferred by splenic CD4+ T cells from the transgenic mice fed with high doses of OVA. The Ag specificity of the suppressor T cells was documented by the failure of spleen cells from mice that were orally tolerant of OVA to suppress irrelevant Ag, KLH-specific airway eosinophilic inflammation. The suppressive effect of the transferred T cells on eosinophil recruitment was neutralized by anti-TGF-beta mAb, but not anti-IFN-gamma mAb, indicating that the suppression is due to the inhibitory effect by secreted TGF-beta, but not to the dominance of the transferred Th1 cells over Th2 cells. This is the first study to reveal a link between oral tolerance and the regulation of Th2-mediated experimental tracheal eosinophilia through TGF-beta. Our experimental model suggests possible therapeutic applications of oral tolerance for the treatment of allergic disorders such as bronchial asthma.

Transglycosylation of intact sialo complex-type oligosaccharides to the N-acetylglucosamine moieties of glycopeptides by Mucor hiemalis endo-beta-N-acetylglucosaminidase

The endo-beta-N-acetylglucosaminidase (endo-beta-GlcNAc-ase) of Mucor hiemalis, endo-M, was found to transfer the sialo complex-type oligosaccharides from transferrin glycopeptide to the N-acetylglucosamine (GlcNAc) moieties of peptidyl-GlcNAc. Disialo complex-type oligosaccharide of transferrin glycopeptide was transferred to 9-fluorenylmethyloxycarbonyl (Fmoc)-asparaginyl-N-acetylglucosaminide (Fmoc-Asn-GlcNAc) by endo-M in a high yield. The structure of the reaction product was confirmed to be Fmoc-Asn-(GlcNAc)2-Man-(Man-GlcNac-Gal-NeuAc)2 by mass spectrometry. Endo-M also transferred disialo complex-type oligosaccharide to the GlcNAc residue of chemically synthesized H-Ile-Asn(GlcNAc)-Ala-Thr-Leu-OH. Asn-linked asialo complex-type oligosaccharide and Asn-linked high-mannose type oligosaccharide were also effective as oligosaccharide donors. Transfer of disialo complex-type oligosaccharide to the GlcNAc-peptide was the most effective among the three types of oligosaccharides, although the disialo complex-type oligosaccharide attached to the peptide was the poorest substrate for the hydrolytic activity of endo-M.

Effects of cardiac surgery on intellectual function in infants and children

Intellectual function was evaluated by Gesell's developmental quotient (DQ) and Binet's intelligence quotient (IQ) in 161 infants and children (61 ventricular septal defects, 49 tetralogies of Fallot, 15 transpositions of the great arteries, seven atrial septal defects, five complete atrioventricular canals, five double outlet right ventricles and 19 shunt cases; average age 3.6 years) before and after cardiac surgery. There were no significant differences in preoperative DQs and IQs among the patient groups. Although average DQ scores in 21 infants with hypothermic (13-24 degrees C) total circulatory arrest (36-70 min) were not significantly different from the preoperative values, 13 patients with an arrest time > 50 min showed a significant decrease in DQ scores. The postoperative DQ and IQ scores in patients without circulatory arrest or in shunt cases were not significantly impaired after surgery. It was concluded that cardiac surgery did not impair intellectual function in infants and children, although cerebral dysfunction might occur if circulatory arrest was > 50 min.

[Surgical management of vascular ring in 5 cases]

Five cases of vascular ring are presented. Three cases have double aortic arch and two cases have right aortic arch with aberrant left subclavian artery. Other congenital heart diseases are complicated in four cases. MRI was useful for the evaluation of tracheal and esophageal compression.

[Surgical management of infective endocarditis in childhood]

From 1971 to 1993, four patients, 7 to 13 years of age, underwent intracardiac operation for infective endocarditis. Two patients underwent mitral valve replacements, one was tricuspid replacement and one received tricuspid valvulectomy. There was no operative death but one late death occurred (correction of occurred) due to cerebral bleeding. Surgical treatment of infective endocarditis in childhood could be performed safely by adequate selection of operative methods.

[Systemic-pulmonary artery shunt using Golaski graft: trial for measurement of the shunt flow]

For the systemic-pulmonary artery shunt operation, the modified Blalock-Taussig shunt was the first choice for procedure in our institution. Since 1990, Golaski knitted Dacron graft (4 or 5 mm in diameter) was used for the prosthesis. Ex-vivo flow calibration of the electromagnetic flow meter (Nihon Koden, MFV-3100) to Golaski graft showed good correlation between the real flow and value measured by the electromagnetic flow meter. Shunt flow was measured in the consecutive clinical fifteen cases. The shunt flow per body surface area of the patient who required additional shunt operation was 721 ml/min/m2 and one patient in whom the congestive heart failure developed after the shunt operation, had the shunt flow of 3,022 ml/min/m2. The adequate shunt flow in these cases was ranged from 745 to 2,820 ml/min/m2 (mean +/- 1 SD, 1,490 +/- 587.8). Therefore we performed the systemic-pulmonary artery shunt operation using Golaski graft to get the shunt flow of 1,000 ml/min/m2 (approximately a third of cardiac index) for the guide of good results.

[Insertion of prosthetic tricuspid valve two years after the tricuspid valvulectomy]

A case of a 14-year-old boy who underwent a prosthetic tricuspid valve insertion two years after the tricuspid valvulectomy due to intractable right-sided active endocarditis is presented. At the initial operation, the tricuspid valve was thoroughly resected because of marked destruction and attachment of vegetations, and a concomitant ventricular septal defect was directly closed. When a prosthetic valve was placed in the tricuspid portion, a semicircular Dacron patch was attached to the right side of the interventricular septum in a fashion of up-chord and down-arc to cover the bundle of His. The straight edge of the patch was located near the AV node and was not sutured to the tricuspid valve annulus. A 31 mm of CarboMedics prosthetic valve was sutured to the tricuspid valve annulus and to the free edge of the patch at the position near the AV node to prevent AV block. Postoperative course was uneventful and ECG showed regular sinus rhythm.

Late results after correction of ventricular septal defect with severe pulmonary hypertension

Fifty-eight patients with ventricular septal defect (VSD) associated with severe pulmonary hypertension (Pp/Ps > or = 0.90) were repaired between 1971 and 1992. Their preoperative Pp/Ps, Rp/Rs and Rp were 0.98 +/- 0.06, 2.37 +/- 1.20 and 4.81 +/- 3.06 units.m2, respectively. Late results were analyzed in 56 operative survivors. The age at the time of operation ranged from 2 months to 32 years (average 4.1 years) and the postoperative follow-up period ranged from 1 month to 20 years (average 5.5 years). Eighty-two percent of the patients were in New York Heart Association functional class I, 15% were in class II and 3% in class III. The postoperative Pp/Ps and Rp/Rs significantly decreased to 0.41 +/- 0.13 (p < 0.001) and 0.25 +/- 0.16 (p < 0.001), respectively. There were significant differences in Rp/Rs and Rp between the patients operated on before (Group 1) and after 2 years of age (Group 2). Rp/Rs and Rp in Group 1 were 0.17 +/- 0.06 and 2.52 +/- 0.65 units.m2, whereas 0.31 +/- 0.19 (p < 0.05) and 4.26 +/- 1.88 units.m2 (p < 0.05) in Group 2, respectively. One patient died 14 months after VSD closure due to respiratory failure. It is concluded that a patient with VSD associated with severe but reversible pulmonary hypertension should be surgically corrected before 2 years of age.

Pulmonary arterial changes in patients dying after a modified Fontan procedure following pulmonary artery banding

Pulmonary arterial changes were histometrically analyzed in four cases of postoperative death following a modified Fontan procedure in which pulmonary artery banding had previously been performed because of pulmonary hypertension. Case 1 was a 3-year-old girl with corrected transposition of the great arteries (TGA), ventricular septal defect, and double-inlet left ventricle; case 2 was a 6-year-old girl with single ventricle (SV) and complete TGA; case 3 was a 25-month-old boy with SV and double-outlet right ventricle; and case 4 was a 21-year-old man with tricuspid atresia. The cause of death in cases 1, 2, and 3 was pulmonary hypertensive crisis due to postoperative vasoconstriction of the small pulmonary arteries. Medical hypertrophy remained in half of the preacinar small pulmonary arteries although it was not observed in all the intraacinar arteries in cases 1 and 2, even after banding. The postoperative course of case 4 was uneventful despite multiple thromboembolism in the small pulmonary arteries. However, the patient died due to a thrombosed artificial valve. The results suggest that residual medial hypertrophy of the small pulmonary arteries was a major risk factor in these cases. Lung biopsy is recommended to determine the indications for the Fontan procedure in these hemodynamically critical cases.

Experimental study of cerebral autoregulation during cardiopulmonary bypass with or without pulsatile perfusion

Twenty-four adult mongrel dogs were divided into four equal groups according to the following method of cardiopulmonary bypass: normothermic continuous (so-called nonpulsatile) perfusion, normothermic pulsatile perfusion, hypothermic continuous perfusion, and hypothermic pulsatile perfusion. Cerebral blood flow was determined by measuring the volume of sagittal sinus venous blood outflow with a transit-time ultrasonic flowmeter. Cardiopulmonary bypass was initiated at a flow rate of 80 ml/kg per minute. Cerebral temperature was maintained at 37 degrees C in the normothermic groups and at 25 degrees C in the hypothermic groups. Arterial pH and carbon dioxide were maintained within the physiologic range by alpha-stat acid-base regulation. Mean cerebral perfusion pressure and blood flow were not affected during 90 minutes of the bypass. The respective values were 67.1 mm Hg and 37.1 ml/100 gm brain per minute with normothermic continuous perfusion, 72.8 mm Hg and 39.0 ml/100 gm per minute with nonpulsatile perfusion, 98.0 mm Hg and 23.0 ml/gm per minute with hypothermic continuous perfusion, and 86.8 mm Hg and 22.3 ml/100 gm per minute with hypothermic pulsatile perfusion. Pump flow rates were altered from 10 to 120 ml/kg per minute in a stepwise fashion to obtain graded changes of perfusion pressure. Cerebral blood flow, however, was not changed significantly by cerebral perfusion pressure so long as perfusion pressure was greater than 50 mm Hg. Conversely, cerebral blood flow changed proportionally with cerebral perfusion pressure at a pressure less than 50 mm Hg. The correlation between cerebral blood flow and perfusion pressure was described as two separate lines determined by linear regression. The slope of the regression line relating cerebral blood flow to perfusion pressure was 0.16 +/- 0.08 for a cerebral perfusion pressure above 50 mm Hg and 0.68 +/- 0.11 below 50 mm Hg in the normothermic continuous perfusion group; 0.14 +/- 0.09 and 0.32 +/- 0.09 with normothermic pulsatile perfusion; 0.10 +/- 0.04 and 0.62 +/- 0.18 with hypothermic continuous perfusion; 0.09 +/- 0.08 and 0.39 +/- 0.04 in the hypothermic pulsatile perfusion group. The slope above 50 mm Hg was significantly smaller and closer to zero in all groups than it was at a perfusion pressure below 50 mm Hg (p < 0.05).(ABSTRACT TRUNCATED AT 400 WORDS)

[Comparison of the late hemodynamics following corrective surgery of congenital heart diseases: ventricular septal defect, tetralogy of Fallot, Mustard operation and Fontan operation]

Late hemodynamics following corrective surgery for congenital heart diseases were evaluated in 65 patients. The patients were divided into 4 groups due to the operative procedures including closure of ventricular septal defect (VSD group = 15 patients), repair of tetralogy of Fallot (TOF group = 20), Mustard operation (Mustard group = 19) and Fontan operation (Fontan group = 11). The postoperative period was 3.8 +/- 3.8, 1.0 +/- 0.1, 5.7 +/- 4.3 and 3.2 +/- 4.9 years in VSD, TOF, Mustard and Fontan groups, respectively. Postoperative pulmonary to systemic arterial pressure ratio in VSD group significantly decreased to 0.38 +/- 0.13 from the preoperative value of 0.97 +/- 0.04. Pulmonary vascular resistance (Rp) in VSD group significantly decreased from 4.88 +/- 2.40 to 2.56 +/- 0.75 U.m2 and Rp in Fontan group significantly increased from 1.63 +/- 0.70 to 3.66 +/- 0.47 U.m2 postoperatively. Postoperative cardiac indices in VSD, TOF, Mustard and Fontan groups were 4.30 +/- 1.34, 4.28 +/- 0.72, 3.83 +/- 1.38 and 3.48 +/- 1.38 l/min/m2, respectively, without significant differences. Ejection fraction (EF) of the systemic ventricle (left ventricle) in VSD, TOF and Fontan groups were 0.66 +/- 0.06, 0.65 +/- 0.07 and 0.63 +/- 0.08, respectively. In Mustard group, EF of the systemic ventricle (right ventricle) was 0.56 +/- 0.12 and significantly less than left ventricular EF in the other 3 groups. The hemodynamic characteristics after these operative procedures should be considered for patient management.

Cytosaminomycins, new anticoccidial agents produced by Streptomyces sp. KO-8119. I. Taxonomy, production, isolation and physico-chemical and biological properties

Streptomyces amakusaensis KO-8119, a soil isolate, was found to produce a series of new anticoccidial compounds. Four active compounds, designated as cytosaminomycins A, B, C and D, were isolated from the fermentation broth of the producing strain by solvent extraction, silica gel column chromatography and preparative HPLC. Cytosaminomycins inhibited the growth of Eimeria tenella in an in vitro assay system using primary chicken embryonic cells as a host. No schizont in the cells was observed at concentrations ranging from 0.3 to 0.6 microgram/ml for cytosaminomycins A, B and C, and at 2.5 micrograms/ml for cytosaminomycin D.

Cytosaminomycins, new anticoccidial agents produced by Streptomyces sp. KO-8119. II. Structure elucidation of cytosaminomycins A, B, C and D

Structures of novel anticoccidial antibiotics, cytosaminomycins A, B, C and D, were elucidated by NMR studies. Cytosaminomycins were shown to be nucleoside antibiotics related to oxyplicacetin. Their carboxylic acid moieties bonded to the cytosine residue were different from that of oxyplicacetin. The carboxylic acids contained in cytosaminomycins A, B, C and D were (E)-3-(methylthio)acrylic acid, 4-methylaminobenzoic acid, 3-methylcrotonic acid, and tiglic acid, respectively.

Tricuspid valve myxoma in a child with coronary artery occlusion and aneurysms

The case of a 13-year-old boy with a tricuspid valve myxoma and coronary artery occlusion and aneurysms suspected to be caused by Kawasaki's disease is presented. Simultaneous extirpation of the myxoma and coronary artery bypass grafting to the left anterior descending artery using the left internal mammary artery was performed. His postoperative course was satisfactory. Coronary artery bypass grafting in a child is also discussed.

[A clinical study of respiratory complication after cardiopulmonary bypass, with special reference to complement activation, WBC and granulocyte elastase]

Complement activation and it's influence on lung injury were studied in 20 patients undergoing cardiopulmonary bypass (CPB). Anaphylatoxins increased remarkably to 3130 +/- 1770 ng/ml in C3a, 2480 +/- 2530 ng/ml in C4a and granulocytes were significantly fewer in left atrium (LA) than right atrium (RA) during CPB. Granulocyte elastase (GEL) was significantly higher in LA than RA at the time of reperfusion. Postoperative respiratory index was well correlated with C3a and GEL. We concluded that lung injury after CBP was caused by anaphylatoxin which aggregated granulocyte in pulmonary vasculature and released GEL during CPB, and anaphylatoxin was produced not only by using CBP but in patient's lung.

[Autologous vs bovine pericardial valved patch for widening of the right ventricular outflow tract of tetralogy of Fallot]

Autologous or glutaraldehyde treated bovine pericardial valved patch was utilized for widening of the right ventricular outflow tract in 20 patients with tetralogy of Fallot (autologous pericardium group in 10 patients and bovine pericardium group in 10). Pericardial valve function of the both materials was evaluated by postoperative cardiac catheterization performed 1 year after the operation. There were no significant differences in pulmonary arterial and right ventricular pressures, and right ventricular ejection fraction and end-diastolic volume between the 2 groups. Pulmonary angiogram in the autologous pericardium group patients demonstrated the pulmonary regurgitation (PR) of grade 1 in 5 patients, grade 2 in 4 and grade 3 in 1. On the other hand, 1, 3 and 6 patients in the bovine pericardium group demonstrated no-PR, grade 1 PR and grade 2 PR, respectively. It was concluded that there were no significant differences between autologous and glutaraldehyde treated bovine pericardium as a material of valved patch for widening of the right ventricular outflow tract of tetralogy of Fallot.

Arohynapenes A and B, new anticoccidial agents produced by Penicillium sp. Taxonomy, fermentation, and structure elucidation

Penicillium sp. FO-2295, a water isolate, was found to produce a series of new anticoccidial compounds. Two active compounds, designated arohynapenes A and B, were isolated from the fermentation broth of the producing strain by solvent extration and preparative HPLC. Arohynapene A was deduced to be (2E,4E)-5-(5-hydroxy-2,6,8-trimethyl-5,6,7,8-tetrahydronaphtale ne)-2,4- pentadienoic acid, and arohynapene B was (2E,4E)-5-(2-hydroxymethyl-6,8-dimethyl-5,6,7,8-tetrahydronapht alene)-2,4- pentadienoic acid. Arohynapenes inhibited the growth of Eimeria tenella in an in vitro assay using BHK-21 cells as a host. No schizont in the cells was observed at concentrations ranging above 35.0 microM and 7.0 microM for arohynapenes A and B, respectively.

Protection of the brain during hypothermic perfusion

The adequacy of the circuits for brain perfusion has been explored by hemodynamic assessment using the ability of the brain to autoregulate blood flow as an indicator, and by morphologic observation using carbon black or Evans blue infusion into the brain perfused antegradely or retrogradely. It is concluded that the safe pressure of cerebral perfusion needed to maintain cerebral integrity is between 40 and 50 mm Hg in both normothermic and hypothermic perfusions, a pressure that can be generated by nonpulsatile pump flows through the pump greater than 40 mL.kg-1 x min-1. Morphologic studies revealed development of focal infarctions in the brain and destruction of the blood-brain barrier by retrograde cerebral perfusion. The retrograde approach, therefore, is definitely inferior to the antegrade method. Antegrade perfusion for 90 minutes, however, produced minimal cerebral edema, suggesting the need for further improvement even in techniques of antegrade perfusion.

Hynapenes A, B and C, new anticoccidial agents produced by Penicillium sp. I. Production, isolation and physico-chemical and biological properties

Penicillium sp. FO-1611, a soil isolate, was found to produce a series of new anticoccidial compounds. Three active compounds, designated hynapenes A, B and C, were isolated from the fermentation broth of the producing strain by solvent extraction, silica gel column chromatography, gel filtration on Sephadex LH-20 and preparative HPLC. Hynapenes inhibited the growth of Eimeria tenella in an in vitro assay using BHK-21 cells as a host. No schizont in the cells was observed at concentrations ranging above 123 microM, 34.7 microM and 34.7 microM for hynapenes A, B and C, respectively.

Risk analysis of low cardiac output syndrome after valve replacement

In order to obtain a better understanding of the pathogenesis of the postoperative low cardiac output syndrome (LOS), a multivariate regression analysis was performed, evaluating predictive risk factors quantitatively as a function of plural preoperative variables. A total of 145 cases including 76 MVR (MS 36 MR 40), 42 AVR and 27 DVR were analyzed in this study. Ten historical, 10 hemodynamic and 4 operative risk factors were collected to compose the data file with corresponding status of postoperative cardiac function which was classified as follows. Patients who were not associated with postoperative LOS (Score 1), associated with the LOS which required and responded to ordinal dosage of a catecholamine (Score 2) associated with the LOS which required and responded to maximal dosage of the catecholamine and/or mechanical circulatory support (Score 3), and died of LOS (Score 4). Variables with significant relationships to postoperative LOS, regression equation to LOS score and their multiple correlation coefficients (R) of each group were as follows. MVR group: technical trouble (TT), extracorporeal circulation time (ECCT), change of myocardial preservation methods, delta LVSWI/delta LVEDP, diseased duration, aortic cross clamping time, CTR, Y = -1.16 + 1.01 (TT) + 0.05(ECCT) + 0.16(delta LVSWI/delta LVEDP) + 0.02(CTR), R = 0.76. AVR group: LVMMI, ECCT, cardiac failure, NYHA, Y = -0.71 + 0.03(LVMMI) + 0.004 (ECCT) + 0.22(NYHA), R = 0.78. DVR group: delta LVWI/delta LVEDP, LVMMI, NYHA, LV diastolic eccentricity ratio, ECCT, Y = -0.50 + 0.60 (delta LVWI/delta LVEDP) + 0.003(LVMMI) + 1.18(NYHA) + 0.38(delta LVSWI/delta LVEDP) + 0.003(ECCT), R = 0.87. It was demonstrated that preoperative ergometer exercise study during cardiac catheterization was useful in prediction of postoperative outcomes, especially in the MVR (MS) group.