P2528Responsiveness to nutritional intervention would impact on future cardiovascular prognosis in poor fitness patients

Purpose

Nutritional improvement has been proposed for long-term cardiovascular prognosis as well as fitness recovery. We aimed to examine whether “responsiveness” to nutritional and exercise interventions would impact patients' cardiovascular prognosis even patients in low baseline fitness level.

Methods

We included 254 consecutive patients who participated in the phase II comprehensive cardiovascular rehabilitation (CCR) for at least three months. All patients underwent cardiopulmonary exercise test (CPX) at the initial and completion phases of CCR. Nutritional guidance was periodically performed individually during CCR. Peak oxygen uptake (PVO2) was measured through CPX to evaluate the fitness level, whereas nutritional status was evaluated using the geriatric nutritional risk index (GNRI). Patients were divided into “low fitness” and “normal fitness” groups based on the median of baseline PVO2. Each group was further classified into four categories according to the changes in VO2 and GNRI during CCR: “Both NOT improved”, “Only GNRI improved”, “Only PVO2 improved”, and “Both improved”.

Results

Cox proportional regression analysis showed that the category of “both NOT improved” was an independent predictor for cardiovascular risk among the baseline low fitness group (Hazard ratio: 4.5, p=0.007); whereas no significant difference among the normal fitness group. Kaplan-Meier analysis revealed that the event-free survival rate was significantly lower in the “both NOT improved” category (log rank p=0.002) among the baseline low fitness group (figure); whereas no significant difference among the normal fitness group.

GNRI/PVO2 improvement vs. prognosis

Conclusion

Responsiveness to nutritional and exercise intervention could be a predictive factor of cardiovascular prognosis even in low fitness patients.

Prognostic factors for survival after embolization of hepatic metastases in uveal melanoma

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Background: Liver is the most common site of metastasis (>80%) in patients with uveal melanoma. Embolization of the hepatic artery has been used to control hepatic metastases. Methods: Uveal melanoma patients with hepatic metastases embolized with iodized poppy seed oil and gelatin sponge, and either BCNU (chemoembolization, CE) or GM-CSF (immunoembolization, IE) during periods when each of these drugs was the agent of first choice, were evaluated. Prognostic factors that predict OS and progression free survival (PFS) in the liver (PFS-L) and in the extra-hepatic systemic organs (PFS-S) were analyzed univariately using the log-rank test and multivariately using Cox proportional hazards model. The following parameters were evaluated: age, gender, pre-existing extrahepatic metastases (EHM), LDH, AST, ALP, and treatment modality (CE or IE). Results: A total of 53 uveal melanoma patients with < 50% liver involvement with melanoma were analyzed. In comparison to the 19 patients (14 males/5 females) who underwent CE, the 34 patients who underwent IE (12 males/22 females) have significantly better OS (14.1 vs. 9.7 months, p=0.012) and PFS-S (10.2 vs. 4.8 months, P=0.013) in univariate analyses. Female patients outlived male patients (14.2 vs. 9.7 months, p=0.005). In Cox model, the shorter OS was associated with male gender (hazard ratio (HR)=2.1; 95% CI, 1.1–4.0; p=0.020), and marginally related to EHM (HR=1.8; 95% CI, 1.0–3.4; p=0.052). Independent predictors of shorter PFS-S included older age (HR=1.04 per year; 95% CI: 1.01–1.06; p=0.007), EHM (HR=2.1; 95% CI, 1.1–3.8; p=0.017), and CE (HR=2.1; 95% CI, 1.2–3.8; p=0.012). The gender-by-treatment interaction was also considered in all Cox models, but it was not significant. None of the covariates was a predictor of PFS-L in univariate or multivariate analyses. Conclusions: IE and female gender were found to be positive prognostic factors for survival after embolization of hepatic metastases.

No significant financial relationships to disclose.

Infective endocarditis in congenital heart disease: Japanese national collaboration study

OBJECTIVE

To provide pure cohorts of paediatric and adult patients with congenital heart disease (CHD) and infective endocarditis (IE) for making future guidelines.

DESIGN

Japanese nationwide survey.

SETTING

66 Japanese institutions.

PATIENTS

170 children, mean (SD) age 7.4 (5.7) years (range 14 days to 17 years), and 69 adults, age 32.5 (14.1) years (range 18-69) who developed IE between 1997 and 2001 (one in 240 admissions with CHD).

MAIN OUTCOME MEASURES

Clinical presentation of IE.

RESULTS

119 patients including 88 with cyanotic CHD had previous cardiac surgery. Procedures preceding IE were dental (12%) followed by cardiovascular surgery (8%). Sites of infection were left sided in 46% and right sided in 51%. Vegetation with diameter of 11 mm was documented in 151 (63%). Frequent complications were embolic events (stroke 11%, other emboli 20%) and cardiac failure (23%). The most common microorganisms were streptococci (50%) and staphylococci (37%) with methicillin resistant Staphylococcus aureus in 7.5%. Empirical treatments were penicillins (alone or with other antibiotics 57%) followed by cephems (22%) and vancomycin (11%). Surgery during active IE was common (26%), with vegetation (45%) and heart failure (29%) as the most frequent indications. Mortality was 8.8%: 8.0% among patients who received medical treatment alone and 11.1% among those with active IE who underwent surgery. The causes of death (n = 21) were surgery (7), infection (7), cardiac failure (6), and renal failure (1).

CONCLUSIONS

Because of a recent increase in the incidence of IE and high mortality and complication rate, it is mandatory to establish well formulated recommendations for management of IE in paediatric and adult patients with CHD based on a large cohort. Results of this nationwide multicentre database should be helpful in establishing guidelines.

Protean manifestations of human papillomavirus type 60 infection on the extremities

BACKGROUND

Human papillomavirus type 60 (HPV-60) induces a ridged wart or an epidermal cyst on the sole of the foot, exhibiting identical pathological changes, with a single refractile eosinophilic intracytoplasmic inclusion body in infected cells. However, there is no information on the role of HPV-60 in the development of cutaneous lesions on other anatomical sites.

OBJECTIVES

To perform the clinicopathological analysis of various cutaneous lesions of a patient in relation to HPV genotype.

PATIENT

A 50-year-old male patient developed multiple papules, plaques and nodules on his hand, arm and legs.

RESULTS

Clinicopathologically, the lesions were classified into three categories. A common wart on the finger showed papillomatosis and acanthosis characterized by numerous keratohyalin granules. Plane warts on the arm showed perinuclear vacuolization of the cells in the upper Malpighian layer. On the other hand, a pigmented papillomatous nodule on the finger, and the other lesions on the hands and legs exhibited similar histological features with a unique cytoplasmic eosinophilic inclusion body. All the three categorized lesions were equally positive for HPV capsid antigen by immunohistochemistry. By blot hybridization analysis for HPV sequences, it was revealed that a common wart on the finger and plane warts on the arm harboured HPV-27 and HPV-3, respectively, while all the other lesions harboured HPV-60. The histological localization of each viral DNA was confirmed in the corresponding lesions by in situ hybridization.

CONCLUSIONS

HPV-60 is able to induce papular and nodular lesions on the extremities.

Isolated noncompaction of ventricular myocardium associated with fatal ventricular fibrillation

A female infant with isolated noncompaction of ventricular myocardium who developed ventricular tachyarrhythmia is described. Wolff-Parkinson-White syndrome was shown by electrocardiography. At 9 months of age, the patient suddenly developed cardiac arrest. Electrocardiography following resuscitation with DC cardioversion demonstrated sinus rhythm without delta wave. The QT interval was normal. Frequent premature ventricular captures caused ventricular fibrillation. DC cardioversion was necessary to terminate frequent attacks of ventricular fibrillation until the introduction of beta blockers and lidocaine. Two-dimensional echocardiogram confirmed the diagnosis of isolated non-compaction of ventricular myocardium. Three months later, the patient died of ventricular fibrillation during respiratory syncytial viral infection.

Plasma monocyte chemoattractant protein-1 and pulmonary vascular resistance in chronic thromboembolic pulmonary hypertension

The pathogenesis of severe pulmonary hypertension seems to be related to inflammatory response in diseased sites. Monocyte chemoattractant protein-1 (MCP-1) has been reported to play a role in the development of congestive heart failure. In this immunological response, activation and migration of leukocytes including macrophages to the inflammatory region are important factors. We hypothesized that the severity of pulmonary hypertension may be related to MCP-1, which is thought to be upregulated by blood pressure or shear stress in pulmonary vasculature as well as by immunological and inflammatory reactions in chronic thromboembolic pulmonary hypertension (CTEPH). Circulating levels of MCP-1, interleukin-1beta (IL-1beta), and tumor necrosis factor-alpha (TNF-alpha) were measured by sandwich ELISA in 14 patients with CTEPH. The plasma level of MCP-1 was significantly correlated with pulmonary vascular resistance. In IL-1beta and TNF-alpha, on the other hand, there was no correlation between cytokines and pulmonary hemodynamics. Pathological specimens obtained from the patients with CTEPH undergoing thromboendarterectomy demonstrated immunoreactivity of MCP-1 in endothelium, smooth muscle cells, and macrophages within neointima in the hypertensive large elastic pulmonary artery. We conclude that MCP-1 is upregulated in the remodeling of pulmonary arteries in close association with increased pulmonary vascular resistance in CTEPH.

Alleviation of myocardial ischemia after Kawasaki disease by heparin and exercise therapy

BACKGROUND

Heparin promotes angiogenesis. We evaluated the effects of combined treatment with heparin and exercise on myocardial ischemia in the chronic stage of Kawasaki disease.

METHODS AND RESULTS

This study was conducted in 7 patients (aged 6 to 19 years) who had a totally occluded coronary artery and stress-induced myocardial ischemia in the collateral-dependent areas. Twice-daily exercise using a bicycle ergometer was performed with increments of 0.5 W/kg every 3 minutes up to maximal exertion for 10 days. Heparin, which immediately increased circulating hepatocyte growth factor, was given intravenously 10 minutes before each exercise period. Newly developed myocardial infarction, ventricular tachyarrhythmia, anginal attack, or hemorrhagic complication was not observed in any patient. Dipyridamole-loading single photon emission computed tomography documented improved myocardial perfusion in the collateral-dependent areas and a significant reduction in total defect scores in all patients after the completion of 20 sessions (P=0.01). In control patients who did not receive the heparin-exercise therapy, however, stress defect scores remained unchanged (n=1) or increased (n=2) during follow-up. Computerized quantitative coronary angiography provided evidence that the heparin-exercise therapy increased the diameter of the occluded artery to which collaterals terminated (P=0.001) but not that of the reference artery with which collaterals were not connected (P=0.96).

CONCLUSIONS

The findings suggest that a series of heparin and exercise treatments over 10 days may have a dramatic effect on the alleviation of myocardial ischemia in collateral-dependent regions. This may be a safe, noninvasive revascularization therapy for patients with coronary artery occlusion in the chronic stage of Kawasaki disease.

Complete nucleotide sequence and analysis of a novel human papillomavirus (HPV 84) genome cloned by an overlapping PCR method

Molecular diagnosis of human papillomaviruses (HPVs) in cervicovaginal samples reveals a plethora of known and novel HPV genomes. We describe the use of an overlapping PCR method to clone and analyze the complete genome of HPV 84 from cervicovaginal cells obtained from a 21-year-old Caucasian female with a normal Pap smear. The 7948-bp complete nucleotide sequence of HPV 84 was determined from five overlapping PCR products by sequence walking. A BLAST homology search demonstrated that HPV 84 was most closely related to HPV 61 (89%), HPV 72 (86%), and HPV 83 (85%) by nucleotide sequence analysis of the L1 open reading frame, placing it in the HPV genome homology group A3. Previously, this virus had been identified as Pap155. Based on extensive epidemiological data, HPV 84 is a highly prevalent genital papillomavirus primarily detected in normal and HIV-infected women.

IgA plasma cell infiltration of proximal respiratory tract, pancreas, kidney, and coronary artery in acute Kawasaki disease

The etiology and pathogenesis of Kawasaki disease (KD) remain unknown. As previously reported, in US patients with acute KD, IgA plasma cells (PCs) infiltrate the vascular wall. To determine whether IgA PCs are increased at mucosal sites in KD and to determine whether other nonvascular KD tissues are infiltrated by IgA PCs, the cells were immunolocalized and quantitated in tissue sections taken from 18 US and Japanese patients who died of acute KD and from 10 age-matched controls. IgA PCs were significantly increased in the trachea of patients who died of acute KD, compared with controls (P<.01), a finding that was similar to findings in children with fatal respiratory viral infection. IgA PCs also infiltrated coronary artery, pancreas, and kidney in all KD patients. These findings strongly support entry of the KD etiologic agent through the upper respiratory tract, resulting in an IgA immune response, with systemic spread to vascular tissue, pancreas, and kidney.

Plasma brain natriuretic peptides and renal hypertension

Three children with renal hypertension are described. Two had histories of neuroblastoma treated by surgical resection and chemotherapy. They both presented later with unilateral atrophic kidney and marked hypertension. Only the child with severe cardiac failure demonstrated high plasma brain natriuretic peptide (BNP) concentrations. The remaining patient had a history of chronic nephritis treated with continuous ambulatory peritoneal dialysis. She also had chronic hypertension and severe cardiac failure. This child demonstrated high plasma BNP levels. The endogenous secretion of BNP is not triggered by hypertension alone, even though exogenous BNP has the pharmacological effect of reducing renin activity.

Doppler flow patterns through the ductus arteriosus in patients with congenital diaphragmatic hernia

We investigated Doppler flow patterns through the ductus arteriosus (DA) of 13 newborn infants with congenital diaphragmatic hernia (CDH) using color Doppler ultrasonography (CDUS). Patterns were classified into 3 types: left-to-right (L-R), bidirectional (BD) and right-to-left (R-L) shunting. Among the 13 patients examined, 3 showed L-R shunting, 5 BD shunting and 5 R-L shunting. Patients with L-R shunting showed significantly better levels of PaO2 and AaDO2 than those with other Doppler flow patterns. However, there were no differences in clinical findings between patients with BD and R-L shunting. All patients with L-R shunting survived after CDH repair without pre-operative stabilization including Lipo-PGE1 (LPE) administration. Four of the 5 patients with BD shunting survived, but only one of the 5 patients with R-L shunting survived after CDH repair following administration of LPE. It was suggested that Doppler flow patterns through the DA may be useful for predicting prognoses and selecting suitable treatment for CDH.

Identification of antigenic proteins encoded by human herpesvirus 8 and seroprevalence in the general population and among patients with and without Kaposi's sarcoma

To establish a sensitive and specific antibody assay, potent antigenic proteins encoded by human herpesvirus 8 (HHV8) were studied. Fifteen recombinant HHV8-encoded proteins were produced as glutathione S-transferase fusion proteins. The sera from AIDS-associated Kaposi's sarcoma (KS) patients reacted with four proteins encoded by open reading frames (ORFs) K8.1, 59, 65, and 73 in a Western blot assay. An enzyme-linked immunosorbent assay (ELISA) using these four proteins as antigens (mixed-antigen ELISA) revealed that all 26 sera derived from KS patients (24 with and 2 without human immunodeficiency virus infection) became positive for anti-HHV8 antibodies. The presence of HHV8 was demonstrated in 14 (1. 4%) of 1,004 sera from the Japanese general population and 10 (1.9%) of 527 sera from patients without HHV8-associated diseases. The presence of immunoglobulin G (IgG) and IgM antibodies against HHV8 examined further by the mixed-antigen ELISA and Western blotting revealed IgG antibody in all ELISA-positive sera, while IgM antibody against ORF K8.1 was absent. These data suggest that the ORF 73 and 65 proteins are potent antigens for a sensitive serological assay.

Expression of tumor necrosis factor-alpha protein in the myocardium in fatal myocarditis

BACKGROUND

Tumor necrosis factor (TNF)-alpha is the most studied cytokine in the failing human heart and in experimental murine myocarditis. We have investigated the expression of TNF-alpha in the myocardium in human myocarditis.

METHODS

We examined endomyocardial biopsy (n = 4) and autopsy (n = 5) tissues obtained from nine patients diagnosed with myocarditis by the Dallas criteria. Expression of TNF-alpha in the hearts was immunohistochemically studied using monoclonal antibodies against human TNF-alpha.

RESULTS

Tumor necrosis factor-alpha protein was expressed in the myocardium of six of the nine patients studied. Four of five fatal patients showed intense immunoreactivity for TNF-alpha compared with survivors. Furthermore, left ventricular systolic function was reduced in patients with TNF-alpha-positive hearts.

CONCLUSIONS

These findings may support the suggestion that TNF-alpha plays an important role in cardiac dysfunction and myocytic damage in fatal human myocarditis.

Molecular cloning, enhancement of expression efficiency and site-directed mutagenesis of rat epidermal cystatin A

A rat cystatin A cDNA clone was isolated from a lambda ZAP library representing newborn rat skin mRNA by screening with a synthetic oligonucleotide designed from amino acid sequence 15-23 of the cysteine proteinase inhibitor. The obtained clone contained a partial coding region of the inhibitor, lacking the 5'-untranslated region and coding sequence for the NH(2)-terminal 13 residues. The amino acid sequence deduced from the base sequence, Glu14-Phe103, coincided with that determined at the amino acid level. To obtain the recombinant cystatin A protein, the DNA was fused with a synthetic linker encoding its missing N-terminal 17 residues and introduced into an expression vector, pMK2. In Escherichia coli, however, the expression level of the semi-synthetic gene was low, 0. 5 mg of the purified recombinant protein per 1 liter culture being produced. Changing of the codon usage of the N-terminal region in a pET-15b expression system led to an increase in the yield depending on the instability of the putative secondary structure around an initiation codon of the mRNA. The expressed cystatin A showed identical characteristics with the authentic form except for the absence of the N-terminal acetyl blocking group. Using the expression system, two kinds of point mutation, the conservative Val54 in the first loop QxVxG region being changed to Lys and Glu, were introduced, but there was almost no effect on the inhibitory activity toward papain. This suggests that the conserved Val in the reactive site is not restricted and that the hydrophobicity of the position is not essential for the activity of rat cystatin A.

Increased expression of mast cell chymase in the lungs of patients with congenital heart disease associated with early pulmonary vascular disease

The molecular mechanism involved in pulmonary vascular disease (PVD) associated with congenital heart disease (CHD) remains uncertain. Evidence suggesting that angiotensin converting enzyme plays an important role in pulmonary vascular pathology led us to hypothesize that mast cell chymase, another angiotensin I converting enzyme, also had the potential to contribute to the development of PVD in CHD. Twenty-three patients 3 mo to 45 yr of age with atrial or ventricular or both septal defects with increased pulmonary arterial blood flow and pressure, with pulmonary vascular resistance ranging from 1.3 to 8.1 units/m(2), were studied. Mast cells and mast cell chymase were immunohistochemically identified in the lung biopsy tissues obtained during corrective surgery. There was a significant difference in numbers of total mast cells between patients (n = 23) and control subjects (n = 10) with normal pulmonary circulation (p < 0.01). Moreover, chymase-containing mast cells in the lung tissues of patients with CHD showed striking differences from those of control subjects. In the patients, 72% of lung mast cells contained chymase, compared with only 15% in control subjects (p < 0.0001). Chymase-containing mast cells predominantly appeared in the media and adventitia of vessel walls. Importantly, angiotensin II was immunohistochemically detected in perivascular lesions where chymase was present, but not in the lesions where chymase was sparsely seen. Furthermore, the number of chymase-containing mast cells was correlated with pulmonary vascular resistance (r = 0.64). These findings suggest a possible role of mast cell chymase in the development of early-stage PVD in patients with CHD.

High prevalence of human papillomaviruses in the normal oral cavity of adults

Human papillomavirus (HPV) infection in the normal oral cavity was studied by the sensitive polymerase chain reaction (PCR) using primers for the L1 region of human papillomavirus DNA and high fidelity amplification system. Cells were scraped from the oral mucosae of 7 (mean age; 42 years) and 30 (mean age; 32 years) volunteers with and without skin warts, respectively. Human papillomavirus DNA was detected in 30/37 (81.1%) specimens and their copy numbers per cell were 10(-1) to 10(-4) (mean, 10(-3)). The human papillomavirus types determined by PCR-based sequencing analysis were HPV-18 (26/30; 86.7%), -61 (18/30; 60%), -59 (7/30; 23.3%), -16 (2/30; 6.7%), -6 (1/30; 3.3%) and an unknown type (HPV-X71) (1/30; 3.3%). Multiple human papillomavirus types were present in 17/30 (56.7%) specimens. HPV-6 was detected in 2 of 7 skin warts and differed from the human papillomavirus types of the corresponding oral specimens. These data suggest that human papillomavirus infection in the oral mucosa occurs much more frequently than previously considered.

Dramatic decrease of circulating levels of monocyte chemoattractant protein-1 in Kawasaki disease after gamma globulin treatment

Kawasaki disease (KD) is a systemic vasculitis preferentially affecting coronary arteries. Extensive monocytes/macrophages infiltrate in the vascular lesions, implying the involvement of a chemotactic cytokine in their recruitment. We investigated the role of monocyte chemoattractant protein-1 (MCP-1, also termed monocyte chemotactic and activating factor) in KD. In the immunohistochemical studies using the cardiac tissues of patients with fatal KD, MCP-1 but not interleukin (IL) -8 or macrophage inflammatory protein-1alpha was localized at the extracellular matrix associated with mononuclear cellular infiltration. The sites of MCP-1 expression correlated with the distribution of the acute inflammation, including early coronary vasculitis. In prospectively studied patients with KD, circulating levels of MCP-1, IL-8, tumor necrosis factor alpha (TNF-alpha), and IL-1alpha were elevated in 73, 77, 57, and 0% of samples before gamma globulin (GG) treatment (400 mg/kg x 5 days = total 2 g/kg), respectively, compared with respective control values. GG treatment correlated with a rapid decrease in the circulating levels of MCP-1 (P = 0.001) but not IL-8 (P = 0.19) or TNF-alpha (P = 0.33). In the sensitive Western blotting, MCP-1 bound to GG. Furthermore, GG inhibited the MCP-1-induced Ca2+ influx in a human monocytic cell line in vitro. These findings suggest a role of MCP-1 in KD, and indicate that GG treatment may block MCP-1 activity, thus alleviating KD vasculitis.

Oral wart associated with human papillomavirus type 2

More than 100 human papillomavirus (HPV) types have been identified to date. Of these, 24 types have been described as being associated with oral lesions. HPV-2 has been frequently associated with skin lesions, but the reports of oral lesions as features of mucosal infection are limited. A biopsy specimen of an oral wart on the right palate was taken from a 48-year-old man and examined for the presence of HPV The sections showed papillary growth of the epithelium with hyperkeratosis and parakeratosis, and koilocytotic changes of the cells located in the upper layers of the oral squamous cell epithelium. These histological features corresponded well to those of verruca vulgaris on the skin. Immunohistochemically, papillomavirus genus-specific capsid antigen was detected in most of the koilocytotic cells. In addition, Southern blot hybridization analysis revealed that the lesion harbored HPV-2 DNA. In situ hybridization with a biotinylated HPV-2 DNA probe clearly demonstrated viral DNA in the nuclei of squamous cells, which were located in a deeper layer of the epithelium than viral antigen-positive cells.

Vascular endothelial growth factor in acute Kawasaki disease

Vascular endothelial growth factor (VEGF), also known as vascular permeability factor, is an important regulator of angiogenesis and blood vessel permeability. Kawasaki disease (KD) is characterized by systemic vasculitis with increased vascular permeability, implying a possible role of VEGF in KD. To elucidate the involvement of VEGF in the pathogenesis of KD, we investigated 30 patients with acute KD, comparing the time course of plasma VEGF levels (n = 123) with clinical symptoms and laboratory findings. Compared with control values, the peak levels of plasma VEGF were significantly elevated (38+/-26 vs 244+/-248 pg/ml, p <0.001). The VEGF levels at the appearance of skin rash and/or edema of hands and feet were also elevated to 176+/-163 pg/ml (p <0.001). In 7 patients (23%), the plasma VEGF levels remained increased after the resolution of the skin rash and peripheral edema. The VEGF levels were independent of gamma globulin therapy and levels of serum albumin and C-reactive protein. We also measured the plasma levels of transforming growth factor-beta1 (TGF-beta1) and tumor necrosis factor alpha, both of which can upregulate VEGF in vitro. The plasma levels of VEGF were highly correlated with those of TGF-beta1 (n = 63, r = 0.73, p <0.001) but not with those of tumor necrosis factor alpha. These findings suggest that the production of VEGF is increased and may be upregulated by TGF-beta1 in acute KD. VEGF may be involved in the hyperpermeability of local blood vessels in acute KD.

Lifelong severe verrucosis associated with human papillomavirus type 2: report of a case with a 38-year follow-up

We describe a 67-year-old woman with disseminated warts which she had had for more than 38 years. The lesions consisted of common and plane warts, wart-like plaques and red-brownish macules similar to those in pityriasis versicolor. Furthermore, during follow-up, several solar keratoses, plaques of Bowen's disease and invasive squamous cell carcinomas were excised. The patient also had T-cell immunodeficiency of unknown aetiology. Histopathology demonstrated that all the warts showed the cytopathological features of common warts, but not those of the warts in epidermodysplasia verruciformis (EV). We investigated the presence of human papillomavirus (HPV) DNA in the warts by blot hybridization and molecular cloning and found that the lesions harboured HPV 2, but not EV-HPVs or other HPVs. In addition, the histopathological distribution of the viral DNA was confirmed in paraffin sections of warts from the patient at different ages by in situ hybridization. However, these investigations yielded negative results in specimens of Bowen's disease and invasive squamous cell carcinoma. These results demonstrated that the patient had been infected with HPV 2 from childhood, but the negative results for detection of DNA of HPV 2 in carcinomas from the patient do not support an oncogenic potential for HPV 2. In conclusion, HPV 2, an aetiological agent of common warts in the general population, may induce a lifelong severe verrucosis in some immunosuppressed patients.

Alleviation of monocrotaline-induced pulmonary hypertension by antibodies to monocyte chemotactic and activating factor/monocyte chemoattractant protein-1

Administration of monocrotaline (MCT) causes pulmonary vascular lesions consisting of monocyte/macrophage infiltration in the early phase and medial thickening in pulmonary arteries and arterioles associated with pulmonary hypertension (PH) in the later phase. However, the molecular mechanism of monocyte/macrophage infiltration and its roles remain elusive. Herein, we have evaluated the role of a potent monocyte chemotactic and activating chemokine/monocyte chemoattractant protein-1 (MCAF/MCP-1) in MCT-induced PH in rats. A single injection of MCT induced PH at Day 21, as evidenced by increases in the ratio of right ventricular to left ventricular and septum weights (RV/LV+S) and right ventricular systolic pressure (RVSP). A significant increase in macrophage number in lungs started at Day 14, reaching a maximum at Day 21. MCAF/MCP-1 levels in bronchoalveolar lavage fluids were elevated significantly at Day 14 and remained high until Day 28, whereas plasma MCAF/MCP-1 levels increased at Day 7, returning to normal levels by Day 21. Immunoreactive MCAF/MCP-1 proteins were mainly detected in macrophages in alveoli and in perivascular regions of pulmonary arterioles and venules. Intravenous administration of anti-MCAF/MCP-1 antibodies with MCT significantly decreased macrophage infiltration and eventually reduced the increases in RV/LV+S and RVSP, as well as medial thickening of pulmonary arterioles. Thus, MCAF/MCP-1 is essentially involved in MCT-induced PH by recruiting and activating macrophages.

Serum thrombopoietin levels in Kawasaki disease

Kawasaki disease (KD) is an acute febrile vasculitic syndrome with thrombocytosis occurring in childhood. Transient thrombocytosis of KD is sometimes the cause of complications such as coronary aneurysmal thrombosis and myocardial infarction. We have analysed blood TPO levels in KD and found that 26/31 acute-phase KD patients had detectable blood TPO levels (mean 173 pg/ml; range 89-294 pg/ml), which decreased immediately with the elevation of platelet counts in 5/12 patients studied. Elevated serum level of TPO may have an important role for this ill-defined disease.

Prevalence of coronary artery abnormalities in Kawasaki disease is highly dependent on gamma globulin dose but independent of salicylate dose

The efficacy of intravenous gamma globulin (IVGG) for treatment of Kawasaki disease (KD) is clearly established. In a metaanalysis, we reviewed U.S. and Japanese multicenter, randomized controlled studies regarding the effect of various doses of IVGG with aspirin administered within the first 7 to 10 days of illness on the prevalence of coronary artery abnormalities in KD. We studied 1629 patients with acute KD from the six reported studies that included blinded echocardiographic assessments. In 868 Japanese patients treated with moderate-dose aspirin (30 to 50 mg/kg per day), the prevalence of coronary abnormalities at the subacute stage (illness day 30) was 26.8% with aspirin alone, 18.1% with total IVGG dose < 1 gm/kg, 17.3% with total IVGG of 1.0 to 1.2 g/kg, and 5.3% with total IVGG of 2 gm/kg; the corresponding prevalence at the convalescent stage of illness (illness day 60) was 17.5%, 13.5%, 9.8%, and 3.5%, respectively. In 761 U.S. patients treated with high-dose aspirin (80 to 120 mg/kg per day), the prevalence of coronary abnormalities at the subacute stage (2 to 3 weeks after enrollment) was 23.0% with aspirin alone, 9.0% with total IVGG of 1.0 gm/kg, 8.6% with total IVGG of 1.6 gm/kg, and 4.6% with total IVGG of 2.0 gm/kg; corresponding prevalence at the convalescent stage (6 to 8 weeks after enrollment) was 17.7%, 9.0%, 6.3%, and 3.8%, respectively. When all data for the 1629 patients were combined, the prevalence at the subacute stage was 25.8% with aspirin alone, 18.1% with IVGG < 1 gm/kg, 15.7% with IVGG of 1 to 1.2 gm/kg, 8.6% with IVGG of 1.6 gm/kg, and 4.8% with IVGG of 2 gm/kg (adjusted R2 = 0.966, p = 0.0017); corresponding prevalence at the convalescent stage was 17.6%, 13.5%, 9.7%, 6.3%, and 3.8%, respectively (adjusted R2 = 0.993, p = 0.0602). The prevalence of coronary abnormalities was inversely related to the total dose of IVGG and was independent of the aspirin dose. We conclude that 2 gm/kg IVGG combined with at least 30 to 50 mg/kg per day aspirin provides maximum protection against development of coronary abnormalities after KD.

Angiographical and computed tomographic findings in diffuse pulmonary arteriovenous fistulas

We reported two rare cases of diffuse pulmonary arteriovenous fistulas in infants and children. Both pulmonary angiography and chest computed tomography were obtained and revealed fine network formations clearly, from which the final diagnosis was made.

Thrombocytopenia: a risk factor for acute myocardial infarction during the acute phase of Kawasaki disease

BACKGROUND

We report on 10 patients with Kawasaki disease and thrombocytopenia who were found to have a high incidence of coronary artery aneurysm and acute myocardial infarction. The clinical features of these patients, the cause of their thrombocytopenia and the relationship between cardiovascular pathology and thrombocytopenia were analyzed.

METHODS

The clinical features of 10 patients with Kawasaki disease found to have thrombocytopenia (group A: mean age 8.0 +/- 7.0 months) and those of 293 patients with Kawasaki disease (group B, controls: mean age 13 +/- 20 months) were analyzed. Coagulation studies and bone marrow aspiration were performed to ascertain the cause of the thrombocytopenia in nine out of 10 subjects in group A.

RESULTS

The minimum platelet count was 4-12 x 10(4)/mm3 (average day of illness, 10.3) and platelet counts were elevated to the baseline value within 1-2 weeks of onset of the illness. Low fibrinogen concentrations, high levels of fibrin degradation products, and low erythrocyte sedimentation rates with high C-reactive protein levels were observed in seven patients. In two other patients, immature megakaryocytes with normal coagulation values were observed. The differences in the incidence of coronary artery aneurysm and acute myocardial infarction between groups A and B were highly significant (coronary artery aneurysm: 60% in group A, 8.9% in group B; acute myocardial infarction: 40% in group A, 0.3% in group B).

CONCLUSIONS

In many patients with Kawasaki disease and thrombocytopenia, the thrombocytopenia appears to be a result of intravascular coagulation, and to be one of the risk factors for acute myocardial infarction.

The absence of evidence of staphylococcal toxin involvement in the pathogenesis of Kawasaki disease

To detect a causative superantigen and to clarify a possible role for staphylococci in Kawasaki disease (KD), culture supernatants of individual bacterial isolates from 11 acute-stage patients were studied. Toxic shock syndrome toxin-1 (TSST-1) and antibody to TSST-1 and enterotoxins A (SEA), B (SEB), and C (SEC) in acute (mean, day 7) and late convalescent (mean, month 15) sera from 26 patients (12 with coronary artery aneurysms) and 22 age-matched controls were measured. Only 1 of 60 supernatants was mitogenic for human lymphocytes; it was 1 of the 4 Staphylococcus aureus isolates. Mitogenicity was neutralized by sera obtained after administration of intravenous gamma globulin (mean, week 4) but not by late convalescent sera. TSST-1 was detectable in 2 of 26 acute sera and 1 of 22 control sera. No KD but 1 control serum had IgM to TSST-1. IgG seroconversion rates to TSST-1, SEA, SEB, and SEC were 10%, 15%, 21% and 16%, respectively. These data do not support the involvement of toxin-producing staphylococci in KD.

Search for highly conserved viral and bacterial nucleic acid sequences corresponding to an etiologic agent of Kawasaki disease

The use of conventional methods to detect a possible infectious cause of Kawasaki disease (KD) has been unsuccessful. Using the polymerase chain reaction and DNA hybridization techniques, we have sought evidence that a known or new herpesvirus, parvovirus, or bacterial pathogen is related etiologically to KD. Peripheral blood DNA from acute KD patients was subjected to amplification and dot-blot hybridization to detect the presence of herpesvirus DNA, and acute KD peripheral blood and serum DNA were subjected to dot-blot hybridization for the presence of parvoviral DNA. All samples were negative for both herpesvirus and parvovirus DNA. In addition, we analyzed buffy-coat white blood cell DNA, synovial fluid DNA, and frozen autopsy and formalin-fixed, paraffin-embedded myocardial tissue DNA from KD patients for the presence of highly conserved bacterial 16S ribosomal RNA gene sequences with the polymerase chain reaction, and all were negative. These results argue against a direct pathogenic role for herpesviruses, parvoviruses, and bacteria in KD. This approach to the detection of highly conserved genomic sequences among broad groups of microorganisms can be adapted for the detection of other groups of microorganisms and may yet prove useful in the search for an etiologic agent of KD.

Anti-hypoxic and anti-ischemic actions of indeloxazine hydrochloride and its optical isomers: possible involvement of cerebral energy metabolism

We evaluated the anti-hypoxic and anti-ischemic actions of indeloxazine hydrochloride ((+/-)-2-[(inden-7-yloxy)methyl]morpholine hydrochloride, YM-08054) in comparison with its optical isomers and several selective monoamine uptake inhibitors in mice. The effects of indeloxazine on both cerebral energy metabolism in normal mice and local cerebral glucose utilization in normal rats were also studied. Indeloxazine and its (-)-isomer, with both serotonin and norepinephrine uptake inhibitory actions, and its (+)-isomer, with a serotonin uptake inhibitory action, prolonged the survival time of mice subjected to nitrogen gas and the gasping duration in decapitated mice. Indeloxazine and its (+)-isomer were approximately 3-10 times more potent than the (-)-isomer with regard to their anti-hypoxic and anti-ischemic activities. Selective norepinephrine uptake inhibitors such as maprotiline and viloxazine, and selective serotonin uptake inhibitors such as citalopram, alaproclate and zimeldine, did not show anti-hypoxic properties. On the other hand, amantadine, a selective dopamine uptake inhibitor, and amitriptyline, a tricyclic antidepressant with anticholinergic properties, significantly shortened the survival time in hypoxic mice. In biochemical studies, increases in brain ATP and glucose levels without affecting lactate level in mice and an elevation in local cerebral glucose utilization in 10 brain regions involving the frontal cortex in rats were observed after administration of indeloxazine. These results suggest that indeloxazine and its optical isomers possess anti-hypoxic and anti-ischemic actions distinct from those of typical monoamine uptake inhibitors, and that these effects of indeloxazine may be due, at least in part, to a facilitation of cerebral energy metabolism.

Pulmonary arteriography with retrograde injection of contrast medium via radial artery: efficacy in neonates with ductus-dependent decreased pulmonary flow

In an attempt to visualize the pulmonary arterial trees of neonates and infants with ductus-dependent decreased pulmonary flow, the efficacy of retrograde injection of contrast from the radial arteries of 11 consecutive patients was tested. All patients had pulmonary atresia and patent ductus arteriosus. A 22- or 24-gauge needle was inserted into the radial artery and contrast medium of 2 ml/kg was injected at flow rates of 3 to 4 ml/sec. The pulmonary arteries were filled by retrograde flow through the ductus arteriosus. This method provided clear visualization of the pulmonary arteries, especially by ductus-sided injections. Developmental anomalies of the pulmonary trunk, localized stenosis at the ductus, and aortopulmonary collateral arteries were demonstrated. No complications occurred during angiography, and all the procedures were completed within 30 minutes. This method appears to be useful in detecting anatomical abnormalities of the pulmonary arteries in neonates and infants with ductus-dependent decreased pulmonary flow.

A study of biohazard protection for farming modules of lunar base CELSS

For the Closed Ecological Life Support System (CELSS) of a manned lunar base which is planned to be built on the moon early in the 21st century, several proposed programs exist to grow vegetables inside a farming module. At the 40th IAF (Malaga, 1989) the author et al presented a proposal for supplying food and nutrients to a crew of eight members, a basic concept which is based on growing four kinds of vegetables. This paper describes measures for biohazard protection in farming modules. In this study, biohazard protection means prevention of the dispersion of plant diseases to other plant species or other portions of farming beds.

The basic health care system for the lunar base crew

A plan of the health care system for the crew on the lunar base is described in this study. The health care system consists of two subsystems. The first is the daily health care system. The system contains health care menus, similar to those on Earth, and some biochemical and ordinary medical examinations. The second system is a periodic medical inspection for the crew's bones and the determination of natural radioisotopes in the body. These care systems are automatically treated with the examination and data filing. Usually these examinations are carried out without the presence of a medical doctor. Examinations and files of the whole results are controlled by a computer. The daily results of examinations are compared with data in the file. If any abnormal values are found in the results, an appropriate message is sent advising whether he must receive an in-depth examination by a medical doctor, or be reexamined by the same submenu. The automatic health care system also records transactions with the life support monitoring system.

Pharmacological studies on novel muscarinic agonists, 1-oxa-8-azaspiro[4.5]decane derivatives, YM796 and YM954

We have investigated the pharmacological profiles of the novel muscarinic agonists, 1-oxa-8-azaspiro[4.5]decane derivatives, YM796 (2,8-dimethyl-3-methylene) and YM954 (2-ethyl-8-methyl-3-oxo). These compounds, like the putative M1 agonists, RS86 and AF102B, inhibited [3H]pirenzepine binding to cerebral cortical membranes in the micromolar range and weakly inhibited [3H]quinuclidinyl benzylate binding to cerebellar membranes. Their (-) isomers had Hill coefficients lower than 1.0. (+/-)-YM796, (+/-)-YM954 and RS86, but not AF102B, stimulated phosphoinositide hydrolysis in hippocampal slices, an effect which is mainly linked to M1 receptors. (+/-)-YM796 (0.031 mg/kg p.o.) and (+/-)-YM954 (0.016 mg/kg p.o.) reversed the cognitive impairment in nucleus basalis magnocellularis-lesioned rats in a passive avoidance task more effectively than did RS86 and AF102B. Similar results were obtained in scopolamine-treated rats. Finally, (+/-)-YM796 was weaker than (+/-)-YM954 and RS86 in the induction of tremor, hypothermia and contraction of isolated ileum, which are mainly mediated by M2 and/or M3 receptors. These results suggest that (+/-)-YM796, (+/-)-YM954 and RS86 have M1 agonistic activity in central nervous system and that (+/-)-YM796 has relatively weak M2 and/or M3 agonistic activity.

Pharmacological profiles of YM-16151-1 and its optical isomers: a novel calcium entry blocking and selective beta-1 adrenoceptor blocking agent

The pharmacological properties of YM-16151-1 [(+/-)-dimethyl 4-[2-[4-(2-hydroxy-3-phenoxypropylamino)butoxyl]-5-nitrop hen yl]-2,6- dimethyl-1,4-dihydropyridine-3,5-dicarboxylate hydrochloride] and its optical isomers were evaluated in in vitro studies and radioligand binding assay. In isolated tissues, YM-16151-1 produced a competitive antagonism of CaCl2-induced contraction in the isolated rabbit aorta with a pKca-1 value of 8.17, and also produced a competitive antagonism of isoproterenol-induced positive chronotropic responses in the isolated rat atria with a pA2 value of 8.47. In rat brain membrane preparations, YM-16151-1 produced dose-dependent inhibitions of [3H]nitrendipine and [3H]dihydroalprenolol bindings with pKi values of 7.21 and 8.07, respectively. Calcium entry blocking activity of YM-16151-1 was 7 times weaker and 3 times greater than nifedipine and diltiazem, respectively. Beta-1 adrenoceptor blocking activity of YM-16151-1 was 2 times weaker than that of propranolol. YM-16151-1 showed about 900-fold selectivity for beta-1 adrenoceptor. YM-16151-1 also showed a weak alpha-1 adrenoceptor blocking activity and its potency was about 13 times weaker than that of phentolamine. S-(-)- and R-(+)-isomers of YM-16151-1 showed the same potency of calcium entry blocking activity. However, in beta-1 adrenoceptor blocking activity, the S-(-)-enantiomer was about 13 to 22 times more potent than the R-(+)-enantiomer. Oral administration of YM-16151-1 produced a dose-dependent blood pressure lowering effect without increasing heart rate in conscious spontaneously hypertensive rats.(ABSTRACT TRUNCATED AT 250 WORDS)

Effects of YM-14673, a new TRH analogue, on behavioral and electrophysiological changes in rats subjected to electrical lesion of the internal capsule

The effects of YM-14673, a new thyrotropin-releasing hormone (TRH) derivative (N alpha-[[(S)-4-oxo-2-azetidinyl]carbonyl]- L-histidyl-L-prolinamide dihydrate), on the pyramidal motor system were studied in comparison with those of TRH in rats subjected to electrical destruction of the left internal capsule, a brain region of the pyramidal motor tract. In this model, neurological deficits such as hemiplegia and decrease of amplitude of electromyographic activity evoked by electrical stimulation of the left sensory motor cortex, were observed on the right legs. Drug administrations were started from 1 day after the surgical operation on and conducted once or several times a day for 13 days. YM-14673 (0.1 mg/kg, i.p., i.v., i.m.; 1 mg/kg, p.o.), unlike its metabolite (M-1) (10 mg/kg, i.p.), accelerated the recovery from neurological deficits. Decrease of evoked EMG activity on the 6th day after surgery was improved by administration of YM-14673 (0.1 mg/kg, i.p.). Intraperitoneal administration of TRH (1-10 mg/kg) once a day did not show any influence on neurological deficits. However, multiple i.p. administrations of TRH seven times in 1 hr accelerated recovery from deficits. These TRH activities are supported by metabolic studies which indicated that a high plasma level of TRH was maintained by multiple administrations of TRH. These results suggest that YM-14673 has a facilitatory effect on the pyramidal motor system which is due, in part, to its TRH-like properties.

Magnetic resonance imaging of myocardial infarction in Kawasaki disease

We performed magnetic resonance imaging in patients with Kawasaki disease following myocardial infarction to assess the usefulness of the technique in detecting myocardial infarction and coronary artery lesions. In six patients (group A), the interval after myocardial infarction was from 7 days to 7 months, and in five patients (group B), it was from 1 to 4 years. Imaging was performed with a superconducting magnet operating at 0.5 T with spin-echo sequence and ECG-gated multiple slices of 5 mm thickness. Myocardial signals were increased in group A, and the region of high signal intensity corresponded to the site of myocardial infarction. The signal intensity within the myocardium was homogeneous in five patients in group B. Coronary arteries were visualized in 20 of 22 instances. Signals within the coronary artery were observed in all 14 instances with poor contrast runoff from the coronary aneurysm, and 11 of these vessels showed high signal intensity. In all six instances in which large aneurysms with severe stenosis were present, signals in the coronary artery were increased. In contrast, high signal intensity in the coronary artery was not observed in five of six instances with good contrast runoff. Signals in the coronary arterial cavity and high signal intensity in the coronary artery persisted in five of six instances with turbulent coronary flow. The findings of increased coronary arterial signals suggested stagnant blood flow in the coronary aneurysm. In conclusion, magnetic resonance imaging was a useful modality for assessment of myocardial infarction and coronary artery lesions in Kawasaki disease.

Abnormal development of fourth aortic arch derivatives in the pathogenesis of tetralogy of Fallot

Aortic arch (AoA) anomalies were studied in 233 patients with tetralogy of Fallot (TOF) of whom some had coexisting pulmonary atresia (PA). There was a 23% incidence of a right AoA in patients without PA, 21% in those with both PA and persistent ductus arteriosus (PDA), and 50% in those with PA and major aortopulmonary collateral arteries (MAPCAs). There was a 5% incidence of an aberrant subclavian artery in patients without PA and a 16% incidence in those with PA and MAPCAs. In this cohort an elongated ascending aorta was observed both with and without high aortic arch. These aortic arch anomalies were frequently associated with PA and MAPCAs.

Class II major histocompatibility antigen expression on coronary arterial endothelium in a patient with Kawasaki disease

To investigate the class II major histocompatibility antigen expression on coronary arterial endothelium of Kawasaki disease and immunophenotypes of the infiltrating cells in the coronary vascular lesions, myocardial sections from a patient who died during the acute stage of Kawasaki disease were studied using an immunoperoxidase technique. The mononuclear cells in the lesions mainly consisted of macrophages and T cells, whereas B cells and NK/K cells were not seen. The majority of T cells reacted with Leu-3a antibodies, and only a few reacted with Leu-2a antibodies. Cells bearing the interleukin-2 receptor, indicative of activated T cells, were also found in the lesions. To determine the distribution of class II antigen, we used anti-HLA-DR antibodies. The massive expression of HLA-DR antigen on mononuclear cells was found in the lesions. In addition, the HLA-DR activation antigen was expressed on the coronary arterial endothelium at the infiltrates in which macrophages and T cells coexisted. In contrast, coronary arterial endothelium did not express HLA-DR antigens in the myocardial tissues of controls (n = 4). HLA-DR+ endothelial cells may play an important role in the development of Kawasaki vasculitis.