A case of neonate effectively treated with everolimus for giant hepatic hemangioma complicated with congenital duodenal atresia and Kasabach-Merritt syndrome

BACKGROUND

Disseminated intravascular coagulation (DIC) with Kasabach-Merrit syndrome from a large hepatic hemangioma is life-threatening. We report a case of giant hepatic hemangioma of the newborn with KMS.

RESULTS

The patient was born at 37 gestational weeks and 2 days via cesarean section; weight at birth was 2952 g. Congenital duodenal atresia was noted during the fetal period. DIC developed after delivery and a giant liver hemangioma was diagnosed via abdominal CT. The cause of DIC was Kasabach-Merritt syndrome owing to a giant hepatic hemangioma. First, combination therapy of 2 mg/kg/day of prednisolone and 0.2 mg/kg/day of propranolol was initiated form enterostomy. However, the size of the hepatic hemangioma did not alter, as observed via image evaluation. Therefore, 0.3 mg/kg/day of everolimus was administered frorm enterostomy. Subsequently, the size of the hepatic hemangioma was assessed via image evaluation. Although it did not alter, blood flow to the hepatic hemangioma decreased and thrombocytopenia was also suppressed. We performed hepatic lateral segmentectomy, radical operation for duodenal atresia. The pathological diagnosis of the removed tumor was infantile hemangioma.

CONCLUSION

We report everolimus may be useful when PSL and propranolol are ineffective.

Comparative studies of the marginal band and plasma membrane of the epidermis

The membranous fraction isolated from stratum corneum by 8M urea-beta ME containing alkaline buffer (pH 9.0) is quite crude when observed by electron microscopy. However, this procedure may be useful for clinical samples, as one can isolate and compare both the soluble (interfilamentous) fraction and the keratin filament from the same sample in addition to the residues (membranous fraction). A further purified membranous fraction was isolated by a new method. Human stratum corneum was chopped and treated with 8M urea-50 mM Tris-HCl (pH 9.0), digested by the use of trypsin, and the product fractionated by a sucrose density gradient to obtain separate single cells without the cytoplasm. One sample was then treated with trypsin for 1 hour and another with urea buffer for 24 hours. Observations revealed a thickened inner membrane (marginal band) of approximately 150A. Each of the membranous samples contained a level of half-cystine markedly higher in amount (around 100/1,000) and involved mostly in the epsilon-(gamma-glutamyl) lysine cross-linkages (around 30%). In order to compare the membranous fraction of horny and living cells (marginal bands and plasma membranes), the fraction was then isolated from living cells. The relative amino acid composition of the membranous fraction of the plasma membrane resembled that of human erythrocytes, but was quite different from that of the marginal band. These comparative studies of biochemical and morphological features suggested the importance of S-S cross-linking enzymes and transglutaminase in the transformation mechanism of the marginal band.

Immunoglobulin prophylaxis against cytomegalovirus infection in patients at high risk of infection following allogeneic hematopoietic cell transplantation

Reports on the efficacy of intravenous immunoglobulin (IVIG) prophylaxis against cytomegalovirus (CMV) infection after allogeneic hematopoietic cell transplantation (HCT) have often sparked controversy. In addition, we are not aware of any study that has examined whether prophylaxis with IVIG affects the incidence of CMV infection in high-risk patients--those who are elderly or have received human leukocyte antigen (HLA) mismatched HCT. In the present open-label, phase II study, we addressed this question. We enrolled 106 patients in the study. The cumulative incidences of CMV infection at 100 days after HCT were similar in the intervention and the control groups (68% and 64%, P=.89; 89% and 87%, P=.79, respectively, for patients 55 years or older and those who received HLA-mismatched HCT). In those who received HLA-mismatched HCT, 1-year overall survival after HCT was 46% in the intervention group and 40% in the control group (P=.31); for age≥55 years, the corresponding values were 46% and 40% (P=.27). Our data showed that prophylaxis with regular polyvalent IVIG did not affect the incidence of CMV infections or survival among older patients or those who receive HLA-mismatched HCT.

Saltiness enhancement by the characteristic flavor of dried bonito stock

There is a pressing need for the development of ways of preparing palatable salt-reduced foods to reduce the salt intake of the Japanese population. The salt-reducing effect of the characteristic flavors other than umami of dried bonito stock, which is widely used in everyday Japanese food, was examined by sensory evaluation. In the 1st sensory evaluation, the effect was evaluated in a model solution. The saltiness of 0.80% NaCl solution was equivalent to that of 0.12% monosodium glutamate (MSG) solution containing 0.81% NaCl and dried bonito stock containing 0.68% NaCl. Saltiness enhancement could not be found when MSG solution was used, but was found with 6% dried bonito stock. The 2nd evaluation examined whether the effect was valid for 2 everyday Japanese foods--traditional Japanese clear soup (sumashi-jiru) and steamed egg custard (tamagodoufu). Although enhancement of saltiness by dried bonito stock could not be clearly demonstrated in the soup, a change in NaCl concentration within 15% did not affect the palatability of the soup. However, dried bonito stock not only enhanced the saltiness but also improved the palatability of steamed egg custard. These findings are expected to be useful for improving the palatability of salt-reduced food.

Accuracy and reliability of continuous blood glucose monitor in post-surgical patients

BACKGROUND

The STG-22 is the only continuous blood glucose monitoring system currently available. The aim of this study is to determine the accuracy and reliability of the STG-22 for continuously monitoring blood glucose level in post-surgical patients.

METHODS

Fifty patients scheduled for routine surgery were studied in surgical intensive care unit (ICU) of a university hospital. After admission to the ICU, the STG-22 was connected to the patients. An attending physician obtained blood samples from a radial arterial catheter. Blood glucose level was measured using the ABL800FLEX immediately after blood collection at 0, 4, 8, and 16 h post-admission to the ICU (total of 200 blood glucose values).

RESULTS

The correlation coefficient (R2) was 0.96. In the Clarke error grid, 100% of the paired measurements were in the clinically acceptable zone A and B. The Bland and Altman analysis showed that bias+/-limits of agreement (percent error) were 0.04(0.7)+/-0.35(6.3) mmol (mg/dl) (7%), -0.11(-2)+/-1.22(22) (15%) and -0.33(-6)+/-1.28(23) (10%) in hypoglycemia (<70(3.89) mmol (mg/dl), normoglycemia (3.89(70)-10(180) mmol (mg/dl), and hyperglycemia (>10(180) mmol (mg/dl), respectively.

CONCLUSIONS

The STG-22 can be used for measuring blood glucose level continuously and measurement results are consistent with intermittent measurement (percentage error within 15%). Therefore, the STG-22 is a useful device for monitoring in blood glucose level in the ICU for 16 h.

Bleeding time prolonged by daily low-dose aspirin is shortened by one medium dose aspirin

BACKGROUND

In planning surgery, a low-dose aspirin regimen for prevention of thrombotic events is often discontinued in order to avoid the risk of excessive bleeding during surgery. However, this procedure increases the risk from adverse thrombotic events. We propose a different method, which may normalize the prolonged bleeding time caused by low-dose aspirin. We verified the effectiveness of this method in healthy volunteers.

METHODS

Volunteers with bleeding time prolonged by taking 81 mg of aspirin a day for a period of 1 week were randomly divided into two groups. The test group of 18 volunteers received a dose of 660 mg of aspirin, while the control group of 16 received placebo. Bleeding time and maximum platelet activity were then evaluated.

RESULTS

Before 660 mg of aspirin or placebo, bleeding time was prolonged: in the aspirin group from 3.1 +/- 0.7 to 6.1 +/- 1.4 min (n=18), and in the placebo group from 2.9 +/- 0.9 to 6.1 +/- 1.5 min (n=16). This prolongation was significant in both groups at the P<0.01 level. In the test group, bleeding time was shortened to 4.5 +/- 1.3 min (P<0.01), which is in the normal range, while it remained prolonged in the control group (6.0 +/- 1.2 min). Platelet activity, on the other hand, was suppressed in both groups.

CONCLUSION

We conclude that 660 mg of aspirin effectively shortens the bleeding time prolonged by daily low-dose (81 mg) aspirin.

A human case of gnathostomiasis nipponica confirmed indirectly by finding infective larvae in leftover largemouth bass meat

A human case of creeping eruption due to Gnathostoma nipponicum was confirmed indirectly by finding infective advanced third-stage larvae in leftover largemouth bass meat. This is the first report indicating that the largemouth bass (Micropterus salmoides) serves as a source of G. nipponicum infection in humans.

Hypercalcemic complication in patients with oral squamous cell carcinoma

Hypercalcemia is one of the metabolic complications associated with cancer. To assess the frequency of hypercalcemia in patients with squamous cell carcinoma (SCC), 242 patients who were evaluated as having SCC in the oral cavity between July 1995 and June 2001 were investigated. All patients were periodically monitored for their serum level of calcium (Ca). Hypercalcemia was defined as a serum Ca concentration higher than 11 mg/dl. By this definition, hypercalcemia was detected in 12 of the 242 patients (5.0%). All 12 patients were at an advanced stage of oral SCC. In these 12 patients, the serum level of parathyroid hormone-related protein (PTH-rP) was also significantly elevated. Therefore, we diagnosed these diseases as humoral hypercalcemia of malignancy (HHM). Moreover, we studied the efficacy of anti-hypercalcemic therapy on the quality of life (QOL). The European Organization for Research and Treatment of Cancer (EORTC) QLQ-C30 was used for estimation of QOL. The patients with HHM who were administrated drugs such as bisphosphonate and calcitonin showed a reduction in their Ca and PTH-rP levels, and the six of ten EORTC QLQ-C30 subscales (emotional functioning, cognitive functioning, fatigue, dyspnoea, nausea/vomiting and appetite loss) were also improved after the anti-hypercalcemic therapy. However, these suppressive effects were temporary. The median survival time after the diagnosis of HHM was only 54.9+/-18.3 days (range 27-86 days). Therefore, HHM in SCC appears to be an ominous prognostic sign. Although anti-hypercalcemic therapy has a palliative role, the patients may be in less discomfort during the terminal stage of their illness.

Effect of three flavonoids, 5,7,3',4'-tetrahydroxy-3-methoxy flavone, luteolin, and quercetin, on the stimulus-induced superoxide generation and tyrosyl phosphorylation of proteins in human neutrophil

The effect of three flavonoids, 5,7,3',4'-tetrahydoxy-3-methoxy flavone (THMF), luteolin, and quercetin, on the stimulus-induced superoxide generation and tyrosyl phosphorylation of proteins in human neutrophils were investigated. When the cells were preincubated with these flavonoids, the superoxide generation induced by N-formyl-methionyl-leucyl-phenylalanine (fMLP) was significantly suppressed, showing a dependence on amounts of the flavonoid. The suppressing effect of the flavonoid was THMF > luteolin > quercetin. These flavonoids also suppressed the superoxide generation induced by phorbol 12-myristate 13-acetate. In this case also, THMF was more effective than luteolin and quercetin. On the other hand, the superoxide generation induced by arachidonic acid was markedly suppressed by quercetin. The suppressing effect was quercetin >> THMF > luteolin. THMF, luteolin, and quercetin significantly suppressed tyrosyl phosphorylation of 80.1-, 58.0-, and 45.0-kDa proteins in fMLP-treated human neutrophils. The suppression depended on the concentration of the flavonoids, and the inhibition of tyrosyl phosphorylation was in parallel to that of the fMLP-induced superoxide generation, respectively. While luteolin and quercetin showed a weak hemolytic activity at 2.5 mM, THMF showed almost no hemolytic activity even at 5 mM, suggesting an advantage of THMF for its clinical use.

Homozygosity mapping to chromosome 5p15 of a gene responsible for Hartnup disorder

Hartnup disorder is an autosomal recessive phenotype involving a transporter for monoamino-monocarboxylic acids. Genetic analysis of the mouse model mapped its locus to human chromosome 11q13 (8). We report here the results of linkage analysis in two Japanese first cousin-marriage families. In the first family, the proband had Hartnup disorder and his deceased older brother was reported to have had typical Hartnup symptoms. The younger brother of the proband was shown to have decreased tryptophan absorption by oral loading test. In the second family, a 6-year-old girl, the proband, had specific hyperaminoaciduria. DNA was isolated from either blood samples or umbilical cord stumps. Genome-wide screening by homozygosity mapping was conducted. Taking into account that the older brother was affected and the younger brother was a carrier in the first family, homozygosity mapping (LOD score = 3.55) and GENEHUNTER (LOD score = 3.28) locates the locus of the Hartnup disorder on 5p15.

Relationship between triglyceride concentrations and LDL size evaluated by malondialdehyde-modified LDL

BACKGROUND

Hypertriglyceridemia is associated with decreased HDL-cholesterol (HDL-C) and increased small dense LDL. In addition, small dense LDL is known to be susceptible to oxidation.

METHODS

We measured LDL particle size, using gradient gel electrophoresis, and malondialdehyde-modified LDL (MDA-LDL), using an ELISA, and investigated the association between triglyceride (TG) concentrations, LDL size, and MDA-LDL.

RESULTS

TG concentrations correlated negatively with the predominant LDL size (r = -0.650) and HDL-C concentration (r = -0.556). The relationship between TG concentration and LDL size, evaluated by measuring MDA-LDL, distinguished subgroups derived from four subfractions of TG concentrations and four distribution ranges of LDL size. These experiments indicated that there is a threshold for oxidation susceptibility at an LDL size of 25.5 nm and a TG concentration of 1500 mg/L. To investigate the relationship between LDL size, MDA-LDL concentration, and other lipids (TGs, HDL-C, apolipoprotein B, and total cholesterol), we evaluated them in control subjects and patients with diabetes mellitus or hypertriglyceridemia. When the size range for normal LDL was postulated to be 25.5 < or = phi (LDL diameter) < 26.5 nm, the MDA-LDL concentration was significantly higher in the subgroups of patients with LDL in the size range 24.5 < or = phi < 25.5 nm compared with patients with normal LDL. This result also suggests that the threshold is at a LDL size of 25.5 nm.

CONCLUSION

The threshold for oxidation susceptibility coincided with the point of LDL size separation between the LDL subclass patterns A and B as an atherosclerotic risk.

[Epidural anesthesia for a patient with catamenial pneumothorax]

Endometriosis extending into the thoracic cage or the lung might induce defect of the tissue and show catamenial symptoms, such as pneumothorax or hemothorax. These events usually occur 48 to 72 hours after menstruation. A 37-year-old woman with ten year history of recurrent catamenial pneumothorax was scheduled for removal of ovarian cyst. Since intermittent positive pressure ventilation or pneumoperitoneum might induce pneumothorax, we selected epidural anesthesia for laparotomy. Epidural cannulations were performed at Th 9/10 and L 4/5 interspaces. After administration of 2% mepivacaine (400 mg) and fentanyl (0.1 mg), the block extended from Th 6 to S 5. The surgery was done without any complication. In this case epidural anesthesia for laparotomy was useful for the patient with catamenial pneumothorax.

An in vitro approach to the evaluation of the cross talk between intestinal epithelium and macrophages

The intestinal epithelium acts as a mucosal barrier by varying their signals to immune cells within the intestine. To observe the cross talk between intestinal epithelium and macrophages, we establish a Caco-2-THP-1 co-culture system. Using this co-culture system, we suggested that paracrine factors of intestinal epithelium increased the phagocytic capacity of intestinal monocytes/macrophages to be ready for immune and inflammatory responses.

Spontaneous regression of merkel cell carcinoma: a comparative study of TUNEL index and tumor-infiltrating lymphocytes between spontaneous regression and non-regression group

Some Merkel cell carcinomas (MCC) have been reported to regress spontaneously. To clarify the mechanisms of spontaneous regression (SR) of MCC, we analyzed the TUNEL index, the labeling index of proliferating cell nuclear antigen (PCNA), the labeling index of bcl-2 protein, and the expression of p53 of the tumor cells. We also evaluated the number of infiltrating lymphocytes surrounding the tumor in the tissue specimens. Among seven patients with MCC (SR: n=4; non-regression (NR): n=3), the TUNEL index in the SR group was significantly higher than that in NR group (5.2 and 2.0%, respectively). In addition, the number of lymphocytes around the tumor nests was also significantly increased in the SR group compared to NR group (1576 and 663 cells/mm(2), respectively). Most of the infiltrating lymphocytes were UCHL-1 positive T-cells. There were no significant differences of the PCNA labeling index, the bcl-2 protein labeling index, and the expression p53 between SR and NR group. These results indicate that apoptosis and local T-cell mediated immune response might be involved in spontaneous regression of MCC.

Human peptidylarginine deiminase type III: molecular cloning and nucleotide sequence of the cDNA, properties of the recombinant enzyme, and immunohistochemical localization in human skin

Peptidylarginine deiminase catalyzes the post-translational modification of proteins through the conversion of arginine to citrulline in the presence of calcium ions. In rodents, peptidylarginine deiminase has been classified into four isoforms, types I, II, III, and IV, which are distinct in their molecular weights, substrate specificities, and tissue localization. Of these isoforms, only type III was detected in epidermis and hair follicles. Although the role of this enzyme in these tissues is not yet clear, indirect data have shown that several structural proteins such as filaggrin, trichohyalin, and keratin are substrates for peptidylarginine deiminase. In this study, we cloned the full-length cDNA of human peptidylarginine deiminase type III (3142 bp) from cultured human keratinocytes by reverse transcription-polymerase chain reaction and by rapid amplification of cDNA ends methods. This cDNA contained a 1995 bp open reading frame encoding 664 amino acids (Mr = 74 770). To explore the physicochemical and enzymatic properties of human peptidylarginine deiminase type III, we constructed a plasmid for producing a recombinant human peptidylarginine deiminase type III in bacteria. The enzymatic characteristics of the recombinant enzyme were very similar to those of the rodent peptidylarginine deiminase type III. The recombinant enzyme showed the catalytic activities toward structural proteins of epidermis and hair follicle, filaggrin and trichohyalin, in which the deiminations maxima of about 60% and 13% arginine residues were observed in filaggrin and trichohyalin, respectively. An immunohistochemical study of human scalp skin with a monospecific anti-peptidyl-arginine deiminase type III antibody revealed that the type III enzyme was localized to the inner root sheath and outer root sheath of hair follicles. Peptidylarginine deiminase type III in the inner root sheath was notable between supramatrix and keratogenous zone and was scarcely detected in cornified hair zone. The enzyme was also expressed in the cuticle layer of hair. On the other hand, expression of the enzyme in the epidermis was very low. These data imply that human peptidylarginine deiminase type III is the predominant isoform in hair follicles and may function as a modulator of hair structural proteins, including trichohyalin during hair and hair follicle formation.

Blood pressure control during eye surgery under local anesthesia using pulse oximetry

We measured the arterial blood pressure and percutaneous O2 saturation (SpO2) in 39 elderly patients (age range, 70-89 years) who underwent cataract surgery under local anesthesia. Nineteen patients showed a 20% or greater increase in the systolic arterial pressure (SAP) measured every minute in the operating room compared to the basal value measured in the ward. We treated elevation of the SAP by intravenous bolus injection of 0.25 mg nitroglycerin (NTG), followed by continuous infusion at 0.1-0.3 microg/kg/min. NTG caused a statistically significant but clinically irrelevant decrease in SpO2 in the patients breathing room air. Two of these patients showed extremely decreased SpO2. Our results suggest that NTG does not typically cause a severe decrease in oxygenation. It might be advisable, however, for patients with severe lung dysfunction or ischemic heart disease to receive prophylactic O2 administration.

A cluster of lysinuric protein intolerance (LPI) patients in a northern part of Iwate, Japan due to a founder effect. The Mass Screening Group

Lysinuric protein intolerance is an autosomal recessive disease characterized by defective transport of the dibasic aminoacids. Mutational analysis of LPI patients in the northern part of Japan revealed that six were homozygous for the R410X mutation and two others were compound heterozygotes of R410X and other unknown mutations. In the population epidemiology study in a local cluster in the northern part of Iwate, ten heterozygotes were found in 1190 newborn babies leading to an estimated LPI incidence of 1/57,000. Polymorphism analysis revealed two major alleles, A and B, in intron 8. While the population frequency of allele A was 0.9 and that of allele B was 0.1 in the northern part of Japan the R410X mutations were exclusively on allele B in 31 chromosomes suggesting a founder effect. Genetic analysis in patients revealed strong linkage disequilibrium with D14S283 and TCRA indicating that the R410X mutation occurred before at least 130 generations ago (about 2600 years). The R410X mutation was shown to be useful as a molecular marker for screening LPI patients in the northern part of Japan.

[General anesthesia for a patient with Cornelia de Lange syndrome]

Cornelia de Lange syndrome involves anomalies in cardio-vascular and musculo-skeletal systems, and mental retardation. In addition, a patient with this syndrome shows a peculiar look. A 22-year-old woman with Cornelia de Lange syndrome underwent general anesthesia twice. She has a small mouth, thin lips, a short neck, short limbs, and stiffness of the neck and some joints associated with slight mental retardation. She was scheduled for arthroscopy and then for rotational acetabular osteotomy and valgus osteotomy. The maximum distance between the upper and lower incisors was 34 mm, when she opened her mouth. Anesthesia was induced with sevoflurane increased slowly to 7.0% in oxygen 6 l.min-1 in both procedures. After the administration of 4% lidocaine 3.5 ml into the pharynx, orotracheal intubation was attempted, but was not successful. Then blind naso-tracheal intubation was performed successfully under spontaneous respiration under sevoflurane-oxygen inhalation. The induction of anesthesia with sevoflurane under spontaneous respiration was useful for blind naso-tracheal intubation in a case with difficult intubation such as in Cornelia de Lange syndrome.

Renal amyloidosis in recessive dystrophic epidermolysis bullosa

BACKGROUND

Although it is known that renal amyloidosis may complicate several dermatoses, recessive dystrophic epidermolysis bullosa (RDEB) complicated by nephropathy has been thought to be rare. We, however, had seen a young adult with RDEB who died of renal failure due to systemic amyloidosis.

OBJECTIVE

A retrospective study was performed in order to investigate the incidence and etiology of renal amyloidosis in RDEB.

METHODS

Routine urinalysis, serum amyloid A protein (SAA) and creatinine levels were repeatedly determined in 11 patients with RDEB (mean age 17.7 years, range 5-28, 7 males, 4 females). Nephropathy was defined as the presence of both proteinuria and hematuria with red blood cell casts.

RESULTS

Seven out of 9 generalized RDEB patients had nephropathy including 3 cases with end-stage renal disease (2 died within 2 years from the onset of nephropathy), while 2 patients with localized RDEB did not. Levels of SAA were significantly higher in patients with nephropathy than those in patients without nephropathy (p<0.05).

CONCLUSION

Nephropathy is a common and serious complication of RDEB. Renal amyloidosis may play an important role in its etiology. We recommend that patients with RDEB should be periodically screened for nephropathy due to amyloidosis by urinalysis and measuring SAA levels.

Probable involvement of a germ-line mutation of an unknown mismatch repair gene in a Japanese Muir-Torre syndrome phenotype

A combination of haplotype analysis and direct sequencing were conducted on Japanese Muir-Torre syndrome kindred. In the kindred, two females revealed a hereditary non-polyposis colon cancer (HNPCC) phenotype and one male had a sebaceous tumor in addition to a HNPCC phenotype. Haplotype analysis and direct sequencing failed to show involvement of the known mismatch repair genes, with the exception of MSH5, in this kindred. Analysis of large fragments (from 3.9 to 6. 2 kb) covering the entire 25 kb MSH5 gene in the proband revealed the absence of gross changes in the promoter region and exons. The direct sequencing of the promoter region and all 25 exons failed to demonstrate any mutations in the coding regions except for a CA repeat polymorphism in intron 3 and a C/A polymorphism in intron 15. Taken together present results indicate that a novel and yet unknown mismatch repair gene is likely involved in the HNPCC in this kindred.

Melanoma in situ of the penis

Melanoma of the penis is rare and the prognosis is very poor. We report a case of melanoma in situ localized on the penile shaft. Melanoma in situ of the penis is extremely rare. We emphasize that early diagnosis of melanoma in situ will improve the prognosis of melanoma of the penis.

Antitumor protein (AP) from a mushroom induced apoptosis to transformed human keratinocyte by controlling the status of prb, c-MYC, cyclin E-cdk2, and p21WAF1 in the G1/S transition

Antitumor protein (AP) from a mushroom, induced the morphological changes typical to apoptosis such as nuclear condensation, aneuploidity, and DNA fragmentation at concentrations as low as 5-20 ng/ml to cancer cells. Molecular alterations related to cell cycle. Molecular alterations related to cell cycle, especially G1/S transition were investigated with a human keratinocyte transformed with oncoproteins, E6 and E7 of human pappiloma virus(HPV)-16. AP didn't alter significantly and oncosuppressor p53 level, but induced hyperphosphorylation of pRb. Time-dependent change of G1 cyclins, cdk2 and cdk4 after addition of AP showed that expression level of cdk inhibitors, INK4 family, and p27KIP1 did not altered, while that of p21WAF1 was downregulated.

Lipodermatosclerosis - report of three cases and review of the literature

We report 3 cases of lipodermatosclerosis (LDS) and discuss the nosology of similar disorders caused by venous insufficiency of the legs. These cases are characterized by (1) occurrence in middle-aged or aged woman, (2) painful, indurated erythema with hyperpigmented scleroderma-like hardening on the lower leg, (3) lobular panniculitis with membranocystic fat necrosis and various degrees of septal fibrosis. Although the designation LDS has been used particularly in the UK and in the USA, this entity is not familiar in other countries including Japan. LDS clinically represents a wide spectrum from an acute, inflammatory phase to a chronic, fibrotic state. The clinicopathologic findings of LDS are similar or identical to the disease previously reported as chronic indurated cellulitis, hypodermitis sclerodermiformis, stasis panniculitis or sclerosing panniculitis. These diseases are probably related conditions, which depend upon the various stages.

Epitope mapping for the anti-rabbit cholesteryl ester transfer protein monoclonal antibody that selectively inhibits triglyceride transfer

Among the monoclonal antibodies (Mab) against rabbit plasma cholesteryl ester transfer protein (CETP), Mab 14-8F cross-reacted with human CETP and selectively inhibited triglyceride transfer but not cholesteryl ester transfer (Ko, K. W. S., T. Ohnishi, and S. Yokoyama. 1994. J. Biol. Chem. 269: 28206;-28213). The epitope of this antibody was studied by using synthetic fragment peptides of rabbit and human CETP. Mab 14-8F reacted with the peptide R451-Q473 of human CETP near the carboxyl-terminal and not with the peptides representing any other regions, and inhibited the binding of human CETP to the goat antibody against its carboxyl-terminal peptide R451-S476. The experiments with a series of the fragment peptides in this region revealed that the epitope requires the segment 465-473 (EHLLVDFLQ) of human CETP or 485-493 (KHLLVDFLQ) of rabbit CETP (core epitope) though neither peptide by itself binds to the antibody. Both peptides needed extension at least by one residue beyond either amino- or carboxyl-end in order to show the reactivity to the antibody, but the effect was not highly residue-specific at least at the amino-end. Circular dichroism analysis demonstrated the increase of helical conformation by the extension of the "core epitope" peptides to either direction. Thus, the epitope is dependent on conformation of the core epitope induced by the presence of an additional residue(s) in either end. The core epitope occupies the central 64% of the reported linear epitope of Mab TP2, a widely used anti-human CETP monoclonal antibody that inhibits both cholesteryl ester and triglyceride transfer.Therefore, we conclude that the limited interaction of Mab with a common lipid interaction site causes selective inhibition of the transfer of triglyceride that has presumably lower priority than cholesteryl ester for the CETP reaction.

[Perioperative management of vagotomy for treatment of frequent syncope]

A 66-year-old man was admitted to our hospital because of frequent chest pain and loss of consciousness. He had a 6-year history of angina and has taken nitroglycerin. He had received total laryngo-pharyngoectomy with the graft by jejunum for pharyngeal cancer seven months ago. The tumor, however, recurred at the neck lymphnodes. Against the increased episodes of severe bradycardia and loss of consciousness, he was scheduled to undergo subemergent vagotomy at proximal and distal side of the cancer since the cancer surrounded the nutrition vessels of the graft. Atropine 0.25 mg i.m. and 0.25 mg i.v. were administered to treat bradycardia and hypotension in the morning of operation. As a premedication atropine 0.5 mg p.o. was given. Anesthesia was induced with midazolam 3 mg, sevoflurane 5%, nitrous oxide 8 l.min-1 in oxygen 4 l.min-1. Intubation through tracheostomy was facilitated with fentanyl 100 micrograms. When the operator touched the neck, heart rate and blood pressure decreased suddenly to 35 beats.min-1 and 62 mmHg/20 mmHg, respectively. Atropine 1 mg i.v. and ephedrine 8 mg i.v. were effective. This was the only episode during surgery. After surgery all bradycardiac episodes have gone away without atropine or any other treatment. His frequent attack of bradycardia and hypotension with syncope was due to vagal reflex by the recurrent tumor.

A case of multiple subungual glomus tumors associated with neurofibromatosis type 1

Glomus tumor is a distinctive neoplasm characterized by the presence of cells that resemble the modified smooth muscle cells of the normal glomus body, which is a specialized form of arteriovenous anastomosis. We report a case of multiple subungual glomus tumors associated with neurofibromatosis and review the literature on the pathophysiology of this association.

Preoperative anxiety is associated with a high incidence of problematic behavior on emergence after halothane anesthesia in boys

BACKGROUND

In our clinical experience, children who are crying before anesthesia are more likely to show agitated behavior on emergence.

METHODS

One hundred and ten boys aged 3-6 years old (ASA 1) who underwent circumcision were studied. The children were assigned to one of two groups, depending on their attitude during induction: the anxious group and the calm group. Anesthesia was induced by inhalation of halothane in oxygen, and was maintained at 1% throughout surgery. For intra- and postoperative analgesia, caudal block with 0.5 ml/kg of 0.25% plain bupivacaine and topical infiltration with 1 to 2 ml of 1% lidocaine were provided for all patients. The incidence of delirium on emergence was compared between the groups.

RESULTS

We excluded 4 boys showing signs of incomplete pain relief. Twenty of 27 boys in the anxious group showed a significantly greater incidence of problematic behavior on emergence, compared to 5 of 79 in the calm group.

CONCLUSION

The boys who were anxious before anesthesia showed a significantly greater incidence of problematic behavior on emergence from halothane anesthesia, compared with the boys who were calm before anesthesia.

Complete atrioventricular block during anesthesia

PURPOSE

To describe a case of asymptomatic first degree atrioventricular block with a bifascicular block that progressed to complete atrioventricular block during anesthesia. This potentially fatal block was successfully treated with transesophageal ventricular pacing.

CLINICAL FEATURES

A 67-yr-old man was scheduled for microvascular decompression of the right trigeminal nerve under general anesthesia. His preoperative ECG showed first degree atrioventricular block with complete right bundle branch block and left anterior hemiblock, but he had experienced no cardiovascular symptoms. Anesthesia was induced with sevoflurane 5%, and maintained with isoflurane 1.5-2% in oxygen. Fifteen minutes later in the left lateral decubitus position, the systolic arterial blood pressure suddenly decreased from 80 mmHg to 0 mmHg. Then, the ECG abruptly changed from sinus rhythm to complete atrioventricular block. The heart was unresponsive to drug therapy such as atropine 1.3 mg and isoproterenol 0.5 mg, or transcutaneous pacing but transesophageal pacing was successful.

CONCLUSION

Asymptomatic first degree atrioventricular block with bifascicular block advanced to complete atrioventricular block during anesthesia. The block was successfully managed with transesophageal pacing.