Removing direct photocurrent artifacts in optogenetic connectivity mapping data via constrained matrix factorization

Monosynaptic connectivity mapping is crucial for building circuit-level models of neural computation. Two-photon optogenetic stimulation, when combined with whole-cell recording, enables large-scale mapping of physiological circuit parameters. In this experimental setup, recorded postsynaptic currents are used to infer the presence and strength of connections. For many cell types, nearby connections are those we expect to be strongest. However, when the postsynaptic cell expresses opsin, optical excitation of nearby cells can induce direct photocurrents in the postsynaptic cell. These photocurrent artifacts contaminate synaptic currents, making it difficult or impossible to probe connectivity for nearby cells. To overcome this problem, we developed a computational tool, Photocurrent Removal with Constraints (PhoRC). Our method is based on a constrained matrix factorization model which leverages the fact that photocurrent kinetics are less variable than those of synaptic currents. We demonstrate on real and simulated data that PhoRC consistently removes photocurrents while preserving synaptic currents, despite variations in photocurrent kinetics across datasets. Our method allows the discovery of synaptic connections which would have been otherwise obscured by photocurrent artifacts, and may thus reveal a more complete picture of synaptic connectivity. PhoRC runs faster than real time and is available as open source software.

Targeted and selective knockout of the TLQP-21 neuropeptide unmasks its unique role in energy homeostasis

OBJECTIVE

Pro-peptide precursors are processed into biologically active peptide hormones or neurotransmitters, each playing an essential role in physiology and disease. Genetic loss of function of a pro-peptide precursor results in the simultaneous ablation of all biologically-active peptides within that precursor, often leading to a composite phenotype that can be difficult to align with the loss of specific peptide components. Due to this biological constraint and technical limitations, mice carrying the selective ablation of individual peptides encoded by pro-peptide precursor genes, while leaving the other peptides unaffected, have remained largely unaddressed.

METHODS

We developed and characterized a mouse model carrying the selective knockout of the TLQP-21 neuropeptide (ΔTLQP-21) encoded by the Vgf gene. To achieve this goal, we used a knowledge-based approach by mutating a codon in the Vgf sequence leading to the substitution of the C-terminal Arginine of TLQP-21, which is the pharmacophore as well as an essential cleavage site from its precursor, into Alanine (R21→A).

RESULTS

We provide several independent validations of this mouse, including a novel in-gel digestion targeted mass spectrometry identification of the unnatural mutant sequence, exclusive to the mutant mouse. ΔTLQP-21 mice do not manifest gross behavioral and metabolic abnormalities and reproduce well, yet they have a unique metabolic phenotype characterized by an environmental temperature-dependent resistance to diet-induced obesity and activation of the brown adipose tissue.

CONCLUSIONS

The ΔTLQP-21 mouse line can be a valuable resource to conduct mechanistic studies on the necessary role of TLQP-21 in physiology and disease, while also serving as a platform to test the specificity of novel antibodies or immunoassays directed at TLQP-21. Our approach also has far-reaching implications by informing the development of knowledge-based genetic engineering approaches to generate selective loss of function of other peptides encoded by pro-hormones genes, leaving all other peptides within the pro-protein precursor intact and unmodified.

All-optical recreation of naturalistic neural activity with a multifunctional transgenic reporter mouse

Determining which features of the neural code drive behavior requires the ability to simultaneously read out and write in neural activity patterns with high precision across many neurons. All-optical systems that combine two-photon calcium imaging and targeted photostimulation enable the activation of specific, functionally defined groups of neurons. However, these techniques are unable to test how patterns of activity across a population contribute to computation because of an inability to both read and write cell-specific firing rates. To overcome this challenge, we make two advances: first, we introduce a genetic line of mice for Cre-dependent co-expression of a calcium indicator and a potent soma-targeted microbial opsin. Second, using this line, we develop a method for read-out and write-in of precise population vectors of neural activity by calibrating the photostimulation to each cell. These advances offer a powerful and convenient platform for investigating the neural codes of computation and behavior.

Targeted and selective knockout of the TLQP-21 neuropeptide unmasks its unique role in energy homeostasis

Pro-peptide precursors are processed into biologically active peptide hormones or neurotransmitters, each playing an essential role in physiology and disease. Genetic loss of function of a pro-peptide precursor results in the simultaneous ablation of all biologically-active peptides within that precursor, often leading to a composite phenotype that can be difficult to align with the loss of specific peptide components. Due to this biological constraint and technical limitations, mice carrying the selective ablation of individual peptides encoded by pro-peptide precursor genes, while leaving the other peptides unaffected, have remained largely unaddressed. Here, we developed and characterized a mouse model carrying the selective knockout of the TLQP-21 neuropeptide (ΔTLQP-21) encoded by the Vgf gene. To achieve this goal, we used a knowledge-based approach by mutating a codon in the Vgf sequence leading to the substitution of the C-terminal Arginine of TLQP-21, which is the pharmacophore as well as an essential cleavage site from its precursor, into Alanine (R ₂₁ →A). We provide several independent validations of this mouse, including a novel in-gel digestion targeted mass spectrometry identification of the unnatural mutant sequence, exclusive to the mutant mouse. ΔTLQP-21 mice do not manifest gross behavioral and metabolic abnormalities and reproduce well, yet they have a unique metabolic phenotype characterized by a temperature-dependent resistance to diet-induced obesity and activation of the brown adipose tissue.

High-performance microbial opsins for spatially and temporally precise perturbations of large neuronal networks

The biophysical properties of existing optogenetic tools constrain the scale, speed, and fidelity of precise optogenetic control. Here, we use structure-guided mutagenesis to engineer opsins that exhibit very high potency while retaining fast kinetics. These new opsins enable large-scale, temporally and spatially precise control of population neural activity. We extensively benchmark these new opsins against existing optogenetic tools and provide a detailed biophysical characterization of a diverse family of opsins under two-photon illumination. This establishes a resource for matching the optimal opsin to the goals and constraints of patterned optogenetics experiments. Finally, by combining these new opsins with optimized procedures for holographic photostimulation, we demonstrate the simultaneous coactivation of several hundred spatially defined neurons with a single hologram and nearly double that number by temporally interleaving holograms at fast rates. These newly engineered opsins substantially extend the capabilities of patterned illumination optogenetic paradigms for addressing neural circuits and behavior.

Post-error recruitment of frontal sensory cortical projections promotes attention in mice

The frontal cortex, especially the anterior cingulate cortex area (ACA), is essential for exerting cognitive control after errors, but the mechanisms that enable modulation of attention to improve performance after errors are poorly understood. Here we demonstrate that during a mouse visual attention task, ACA neurons projecting to the visual cortex (VIS; ACA_VIS neurons) are recruited selectively by recent errors. Optogenetic manipulations of this pathway collectively support the model that rhythmic modulation of ACA_VIS neurons in anticipation of visual stimuli is crucial for adjusting performance following errors. 30-Hz optogenetic stimulation of ACA_VIS neurons in anesthetized mice recapitulates the increased gamma and reduced theta VIS oscillatory changes that are associated with endogenous post-error performance during behavior and subsequently increased visually evoked spiking, a hallmark feature of visual attention. This frontal sensory neural circuit links error monitoring with implementing adjustments of attention to guide behavioral adaptation, pointing to a circuit-based mechanism for promoting cognitive control.

Adolescent frontal top-down neurons receive heightened local drive to establish adult attentional behavior in mice

Frontal top-down cortical neurons projecting to sensory cortical regions are well-positioned to integrate long-range inputs with local circuitry in frontal cortex to implement top-down attentional control of sensory regions. How adolescence contributes to the maturation of top-down neurons and associated local/long-range input balance, and the establishment of attentional control is poorly understood. Here we combine projection-specific electrophysiological and rabies-mediated input mapping in mice to uncover adolescence as a developmental stage when frontal top-down neurons projecting from the anterior cingulate to visual cortex are highly functionally integrated into local excitatory circuitry and have heightened activity compared to adulthood. Chemogenetic suppression of top-down neuron activity selectively during adolescence, but not later periods, produces long-lasting visual attentional behavior deficits, and results in excessive loss of local excitatory inputs in adulthood. Our study reveals an adolescent sensitive period when top-down neurons integrate local circuits with long-range connectivity to produce attentional behavior.

Activation of Somatostatin Interneurons by Nicotinic Modulator Lypd6 Enhances Plasticity and Functional Recovery in the Adult Mouse Visual Cortex

The limitation of plasticity in the adult brain impedes functional recovery later in life from brain injury or disease. This pressing clinical issue may be resolved by enhancing plasticity in the adult brain. One strategy for triggering robust plasticity in adulthood is to reproduce one of the hallmark physiological events of experience-dependent plasticity observed during the juvenile critical period: to rapidly reduce the activity of parvalbumin (PV)-expressing interneurons and disinhibit local excitatory neurons. This may be achieved through the enhancement of local inhibitory inputs, particularly those of somatostatin (SST)-expressing interneurons. However, to date the means for manipulating SST interneurons for enhancing cortical plasticity in the adult brain are not known. We show that SST interneuron-selective overexpression of Lypd6, an endogenous nicotinic signaling modulator, enhances ocular dominance plasticity in the adult primary visual cortex (V1). Lypd6 overexpression mediates a rapid experience-dependent increase in the visually evoked activity of SST interneurons as well as a simultaneous reduction in PV interneuron activity and disinhibition of excitatory neurons. Recapitulating this transient activation of SST interneurons using chemogenetics similarly enhanced V1 plasticity. Notably, we show that SST-selective Lypd6 overexpression restores visual acuity in amblyopic mice that underwent early long-term monocular deprivation. Our data in both male and female mice reveal selective modulation of SST interneurons and a putative downstream circuit mechanism as an effective method for enhancing experience-dependent cortical plasticity as well as functional recovery in adulthood.SIGNIFICANCE STATEMENT The decline of cortical plasticity after closure of juvenile critical period consolidates neural circuits and behavior, but this limits functional recovery from brain diseases and dysfunctions in later life. Here we show that activation of cortical somatostatin (SST) interneurons by Lypd6, an endogenous modulator of nicotinic acetylcholine receptors, enhances experience-dependent plasticity and recovery from amblyopia in adulthood. This manipulation triggers rapid reduction of PV interneuron activity and disinhibition of excitatory neurons, which are known hallmarks of cortical plasticity during juvenile critical periods. Our study demonstrates modulation of SST interneurons by Lypd6 to achieve robust levels of cortical plasticity in the adult brain and may provide promising targets for restoring brain function in the event of brain trauma or disease.

Spatial distribution of tuberculosis in Manaus and its social determinants, 2008-2013

SETTING

Brazil ranks eighteenth worldwide in annual numbers of new tuberculosis (TB) cases. The municipality of Manaus, Amazonas State, has the highest incidence of TB in Brazil.

OBJECTIVE

To evaluate the quality of TB epidemiological surveillance, and to describe the spatial distribution pattern of TB incidence in Manaus and its social determinants.

DESIGN

An ecological study was performed based on secondary data from TB epidemiological surveillance reports.

RESULTS

An index was developed to classify neighborhoods in terms of the quality of surveillance and suspected underreporting. Based on data from neighborhoods with better surveillance performance, we observed that the average number of residents per room, the unemployment rate and the proportion of households connected to a sewage system were significant predictors of TB incidence. Seven neighborhoods in the south and west of the city had clusters of high TB transmission.

CONCLUSION

Our results suggest that the association between TB and social vulnerability is obscured by the poor quality of TB surveillance data. We identified priority areas that require immediate TB control interventions and those where local surveillance efforts should be improved, and generated information useful for formulating more effective actions.

Integrative bioinformatics identifies postnatal lead (Pb) exposure disrupts developmental cortical plasticity

Given that thousands of chemicals released into the environment have the potential capacity to harm neurodevelopment, there is an urgent need to systematically evaluate their toxicity. Neurodevelopment is marked by critical periods of plasticity wherein neural circuits are refined by the environment to optimize behavior and function. If chemicals perturb these critical periods, neurodevelopment can be permanently altered. Focusing on 214 human neurotoxicants, we applied an integrative bioinformatics approach using publically available data to identify dozens of neurotoxicant signatures that disrupt a transcriptional signature of a critical period for brain plasticity. This identified lead (Pb) as a critical period neurotoxicant and we confirmed in vivo that Pb partially suppresses critical period plasticity at a time point analogous to exposure associated with autism. This work demonstrates the utility of a novel informatics approach to systematically identify neurotoxicants that disrupt childhood neurodevelopment and can be extended to assess other environmental chemicals.

VGF function in depression and antidepressant efficacy

Brain-derived neurotrophic factor (BDNF) is a critical effector of depression-like behaviors and antidepressant responses. Here, we show that VGF (non-acronymic), which is robustly regulated by BDNF/TrkB signaling, is downregulated in hippocampus (male/female) and upregulated in nucleus accumbens (NAc) (male) in depressed human subjects and in mice subjected to chronic social defeat stress (CSDS). Adeno-associated virus (AAV)-Cre-mediated Vgf ablation in floxed VGF mice, in dorsal hippocampus (dHc) or NAc, led to pro-depressant or antidepressant behaviors, respectively, while dHc- or NAc-AAV-VGF overexpression induced opposite outcomes. Mice with reduced VGF levels in the germ line (Vgf+/-) or in dHc (AAV-Cre-injected floxed mice) showed increased susceptibility to CSDS and impaired responses to ketamine treatment in the forced swim test. Floxed mice with conditional pan-neuronal (Synapsin-Cre) but not those with forebrain (αCaMKII-Cre) Vgf ablation displayed increased susceptibility to subthreshold social defeat stress, suggesting that neuronal VGF, expressed in part in inhibitory interneurons, regulates depression-like behavior. Acute antibody-mediated sequestration of VGF-derived C-terminal peptides AQEE-30 and TLQP-62 in dHc induced pro-depressant effects. Conversely, dHc TLQP-62 infusion had rapid antidepressant efficacy, which was reduced in BDNF floxed mice injected in dHc with AAV-Cre, and in NBQX- and rapamycin-pretreated wild-type mice, these compounds blocking α-amino-3-hydroxy-5-methyl-4-isoxazolepropionic acid (AMPA) receptor and mammalian target of rapamycin (mTOR) signaling, respectively. VGF is therefore a critical modulator of depression-like behaviors in dHc and NAc. In hippocampus, the antidepressant response to ketamine is associated with rapid VGF translation, is impaired by reduced VGF expression, and as previously reported, requires coincident, rapid BDNF translation and release.

The Prohormone VGF Regulates β Cell Function via Insulin Secretory Granule Biogenesis

The prohormone VGF is expressed in neuroendocrine and endocrine tissues and regulates nutrient and energy status both centrally and peripherally. We and others have shown that VGF-derived peptides have direct action on the islet β cell as secretagogues and cytoprotective agents; however, the endogenous function of VGF in the β cell has not been described. Here, we demonstrate that VGF regulates secretory granule formation. VGF loss-of-function studies in both isolated islets and conditional knockout mice reveal a profound decrease in stimulus-coupled insulin secretion. Moreover, VGF is necessary to facilitate efficient exit of granule cargo from the trans-Golgi network and proinsulin processing. It also functions to replenish insulin granule stores following nutrient stimulation. Our data support a model in which VGF operates at a critical node of granule biogenesis in the islet β cell to coordinate insulin biosynthesis with β cell secretory capacity.

Embryonic ablation of neuronal VGF increases energy expenditure and reduces body weight

Germline ablation of VGF, a secreted neuronal, neuroendocrine, and endocrine peptide precursor, results in lean, hypermetabolic, and infertile adult mice that are resistant to diet-, lesion-, and genetically-induced obesity and diabetes (Hahm et al., 1999, 2002). To assess whether this phenotype is predominantly driven by reduced VGF expression in developing and/or adult neurons, or in peripheral endocrine and neuroendocrine tissues, we generated and analyzed conditional VGF knockout mice, obtained by mating loxP-flanked (floxed) Vgf mice with either pan-neuronal Synapsin-Cre- or forebrain alpha-CaMKII-Cre-recombinase-expressing transgenic mice. Adult male and female mice, with conditional ablation of the Vgf gene in embryonic neurons had significantly reduced body weight, increased energy expenditure, and were resistant to diet-induced obesity. Conditional forebrain postnatal ablation of VGF in male mice, primarily in adult excitatory neurons, had no measurable effect on body weight nor on energy expenditure, but led to a modest increase in adiposity, partially overlapping the effect of AAV-Cre-mediated targeted ablation of VGF in the adult ventromedial hypothalamus and arcuate nucleus of floxed Vgf mice (Foglesong et al., 2016), and also consistent with results of icv delivery of the VGF-derived peptide TLQP-21 to adult mice, which resulted in increased energy expenditure and reduced adiposity (Bartolomucci et al., 2006). Because the lean, hypermetabolic phenotype of germline VGF knockout mice is to a great extent recapitulated in Syn-Cre^+/-,Vgf^{flpflox/flpflox} mice, we conclude that the metabolic profile of germline VGF knockout mice is largely the result of VGF ablation in embryonic CNS neurons, rather than peripheral endocrine and/or neuroendocrine cells, and that in forebrain structures such as hypothalamus, VGF and/or VGF-derived peptides play uniquely different roles in the developing and adult nervous system.

Role of VGF-derived carboxy-terminal peptides in energy balance and reproduction: analysis of "humanized" knockin mice expressing full-length or truncated VGF

Targeted deletion of VGF, a secreted neuronal and endocrine peptide precursor, produces lean, hypermetabolic, and infertile mice that are resistant to diet-, lesion-, and genetically-induced obesity and diabetes. Previous studies suggest that VGF controls energy expenditure (EE), fat storage, and lipolysis, whereas VGF C-terminal peptides also regulate reproductive behavior and glucose homeostasis. To assess the functional equivalence of human VGF(1-615) (hVGF) and mouse VGF(1-617) (mVGF), and to elucidate the function of the VGF C-terminal region in the regulation of energy balance and susceptibility to obesity, we generated humanized VGF knockin mouse models expressing full-length hVGF or a C-terminally deleted human VGF(1-524) (hSNP), encoded by a single nucleotide polymorphism (rs35400704). We show that homozygous male and female hVGF and hSNP mice are fertile. hVGF female mice had significantly increased body weight compared with wild-type mice, whereas hSNP mice have reduced adiposity, increased activity- and nonactivity-related EE, and improved glucose tolerance, indicating that VGF C-terminal peptides are not required for reproductive function, but 1 or more specific VGF C-terminal peptides are likely to be critical regulators of EE. Taken together, our results suggest that human and mouse VGF proteins are largely functionally conserved but that species-specific differences in VGF peptide function, perhaps a result of known differences in receptor binding affinity, likely alter the metabolic phenotype of hVGF compared with mVGF mice, and in hSNP mice in which several C-terminal VGF peptides are ablated, result in significantly increased activity- and nonactivity-related EE.

The VGF-derived peptide TLQP-21 contributes to inflammatory and nerve injury-induced hypersensitivity

VGF (nonacronymic) is a granin-like protein that is packaged and proteolytically processed within the regulated secretory pathway. VGF and peptides derived from its processing have been implicated in neuroplasticity associated with learning, memory, depression, and chronic pain. In sensory neurons, VGF is rapidly increased following peripheral nerve injury and inflammation. Several bioactive peptides generated from the C-terminus of VGF have pronociceptive spinal effects. The goal of the present study was to examine the spinal effects of the peptide TLQP-21 and determine whether it participates in spinal mechanisms of persistent pain. Application of exogenous TLQP-21 induced dose-dependent thermal hyperalgesia in the warm-water immersion tail-withdrawal test. This hyperalgesia was inhibited by a p38 mitogen-activated protein kinase inhibitor, as well as inhibitors of cyclooxygenase and lipoxygenase. We used immunoneutralization of TLQP-21 to determine the function of the endogenous peptide in mechanisms underlying persistent pain. In mice injected intradermally with complete Freund adjuvant, intrathecal treatment with anti-TLQP-21 immediately prior to or 5hours after induction of inflammation dose-dependently inhibited tactile hypersensitivity and thermal hyperalgesia. Intrathecal anti-TL21 administration also attenuated the development and maintenance of tactile hypersensitivity in the spared nerve injury model of neuropathic pain. These results provide evidence that endogenous TLQP-21 peptide contributes to the mechanisms of spinal neuroplasticity after inflammation and nerve injury.

The granin VGF promotes genesis of secretory vesicles, and regulates circulating catecholamine levels and blood pressure

Secretion of proteins and neurotransmitters from large dense core vesicles (LDCVs) is a highly regulated process. Adrenal LDCV formation involves the granin proteins chromogranin A (CgA) and chromogranin B (CgB); CgA- and CgB-derived peptides regulate catecholamine levels and blood pressure. We investigated function of the granin VGF (nonacronymic) in LDCV formation and the regulation of catecholamine levels and blood pressure. Expression of exogenous VGF in nonendocrine NIH 3T3 fibroblasts resulted in the formation of LDCV-like structures and depolarization-induced VGF secretion. Analysis of germline VGF-knockout mouse adrenal medulla revealed decreased LDCV size in noradrenergic chromaffin cells, increased adrenal norepinephrine and epinephrine content and circulating plasma epinephrine, and decreased adrenal CgB. These neurochemical changes in VGF-knockout mice were associated with hypertension. Germline knock-in of human VGF1-615 into the mouse Vgf locus rescued the hypertensive knockout phenotype, while knock-in of a truncated human VGF1-524 that lacks several C-terminal peptides, including TLQP-21, resulted in a small but significant increase in systolic blood pressure compared to hVGF1-615 mice. Finally, acute and chronic administration of the VGF-derived peptide TLQP-21 to rodents decreased blood pressure. Our studies establish a role for VGF in adrenal LDCV formation and the regulation of catecholamine levels and blood pressure.

Germline ablation of VGF increases lipolysis in white adipose tissue

Targeted deletion of VGF, a neuronal and endocrine secreted protein and neuropeptide precursor, produces a lean, hypermetabolic mouse that is resistant to diet-, lesion-, and genetically induced obesity and diabetes. We hypothesized that increased sympathetic nervous system activity in Vgf-/Vgf- knockout mice is responsible for increased energy expenditure and decreased fat storage and that increased β-adrenergic receptor stimulation induces lipolysis in white adipose tissue (WAT) of Vgf-/Vgf- mice. We found that fat mass was markedly reduced in Vgf-/Vgf- mice. Within knockout WAT, phosphorylation of protein kinase A substrate increased in males and females, phosphorylation of hormone-sensitive lipase (HSL) (ser563) increased in females, and levels of adipose triglyceride lipase, comparative gene identification-58, and phospho-perilipin were higher in male Vgf-/Vgf- WAT compared with wild-type, consistent with increased lipolysis. The phosphorylation of AMP-activated protein kinase (AMPK) (Thr172) and levels of the AMPK kinase, transforming growth factor β-activated kinase 1, were decreased. This was associated with a decrease in HSL ser565 phosphorylation, the site phosphorylated by AMPK, in both male and female Vgf-/Vgf- WAT. No significant differences in phosphorylation of CREB or the p42/44 MAPK were noted. Despite this evidence supporting increased cAMP signaling and lipolysis, lipogenesis as assessed by fatty acid synthase protein expression and phosphorylated acetyl-CoA carboxylase was not decreased. Our data suggest that the VGF precursor or selected VGF-derived peptides dampen sympathetic outflow pathway activity to WAT to regulate fat storage and lipolysis.

Role of neurotrophins in the development and function of neural circuits that regulate energy homeostasis

Members of the neurotrophin family, including nerve growth factor, brain-derived neurotrophic factor, neurotrophin-3, and neurotrophin-4/5, and other neurotrophic growth factors such as ciliary neurotrophic factor and artemin, regulate peripheral and central nervous system development and function. A subset of the neurotrophin-dependent pathways in the hypothalamus, brainstem, and spinal cord, and those that project via the sympathetic nervous system to peripheral metabolic tissues including brown and white adipose tissue, muscle and liver, regulate feeding, energy storage, and energy expenditure. We briefly review the role that neurotrophic growth factors play in energy balance, as regulators of neuronal survival and differentiation, neurogenesis, and circuit formation and function, and as inducers of critical gene products that control energy homeostasis.

[Aortic root replacement for aortic dissection and aortic regurgitation due to aortitis syndrome]

Aortic aneurysms and aortic regurgitation (AR) with aortitis syndrome are occasionally reported in young women. We report a case of aortic dissection with severe AR in an 8-year-old girl. The patient underwent aortic root replacement with a composite graft. Pathological report revealed aortitis syndrome and steroid therapy was continued to suppress further inflammatory vascular reaction.

Analysis of knockout mice suggests a role for VGF in the control of fat storage and energy expenditure

Background

Previous studies of mixed background mice have demonstrated that targeted deletion of Vgf produces a lean, hypermetabolic mouse that is resistant to diet-, lesion-, and genetically-induced obesity. To investigate potential mechanism(s) and site(s) of action of VGF, a neuronal and endocrine secreted protein and neuropeptide precursor, we further analyzed the metabolic phenotypes of two independent VGF knockout lines on C57Bl6 backgrounds.

Results

Unlike hyperactive VGF knockout mice on a mixed C57Bl6-129/SvJ background, homozygous mutant mice on a C57Bl6 background were hypermetabolic with similar locomotor activity levels to Vgf+/Vgf+ mice, during day and night cycles, indicating that mechanism(s) other than hyperactivity were responsible for their increased energy expenditure. In Vgf-/Vgf- knockout mice, morphological analysis of brown and white adipose tissues (BAT and WAT) indicated decreased fat storage in both tissues, and decreased adipocyte perimeter and area in WAT. Changes in gene expression measured by real-time RT-PCR were consistent with increased fatty acid oxidation and uptake in BAT, and increased lipolysis, decreased lipogenesis, and brown adipocyte differentiation in WAT, suggesting that increased sympathetic nervous system activity in Vgf-/Vgf- mice may be associated with or responsible for alterations in energy expenditure and fat storage. In addition, uncoupling protein 1 (UCP1) and UCP2 protein levels, mitochondrial number, and mitochondrial cristae density were upregulated in Vgf-/Vgf- BAT. Using immunohistochemical and histochemical techniques, we detected VGF in nerve fibers innervating BAT and Vgf promoter-driven reporter expression in cervical and thoracic spinal ganglia that project to and innervate the chest wall and tissues including BAT. Moreover, VGF peptide levels were quantified by radioimmunoassay in BAT, and were found to be down-regulated by a high fat diet. Lastly, despite being hypermetabolic, VGF knockout mice were cold intolerant.

Conclusion

We propose that VGF and/or VGF-derived peptides modulate sympathetic outflow pathways to regulate fat storage and energy expenditure.

[Pleuroperitoneal communication due to diaphragmatic injury as a complication of chest wall resection in a peritoneal dialysis patient; report of a case]

A 78-year-old female undergoing peritoneal dialysis due to chronic renal failure was admitted to our hospital because of a tumor on her right chest wall. The diagnosis was recurrence of hepatocellular carcinoma in the thoracic wall, and a combined resection of the thoracic wall and diaphragm was performed. Peritoneal dialysis was resumed 7 days after surgery, but a right pleural effusion was observed after 6 days of dialysis. Surgery was performed because failure of sutures related to the excised diaphragm was suspected. A thoracotomy revealed a large defect, about 1 cm in size, caused by injury of the diaphragm by an edge of the resected rib at the another site of a previous resection of the diaphragm. This defect was closed with sutures and the diaphragm was reinforced with a polyglycolic acid felt and fibrin glue. Peritoneal dialysis was resumed 7 days after surgery and has continued to date without recurrence.

[Aortic valve replacement through right thoracotomy; report of a case]

A 78-year-old female was admitted to our hospital with a diagnosis of severe aortic valve regurgitation. She had had dyspnea on effort and syncope twice in 5 months. She had also suffered from right pneumonia 8 years before, and her respiratory function was severely constrictive. Chest X-ray showed her mediastinum significantly shifted toward the right side. Chest computed tomography (CT) revealed the main pulmonary artery, right atrium (RA) and right pulmonary veins also shifted toward the right. We planned right thoracotomy at 4th intercostals space to obtain a good surgical field. A cardiopulmonary bypass was established by RA appendage drainage and femoral artery perfusion. Aortic valve replacement(AVR) was performed successfully after aortic clamp. Though defibrillator pads were placed on her back and the anterior wall of the left chest during operation, no ventricular fibrillation occurred. AVR via right thoracotomy is considered to be a good option for such a mediastinum shifted case.

[Beating heart surgery for the patient of severe mitral regurgitation with a episode of ventricular fibrillation; report of a case]

A 77-year-old female was admitted to our hospital with a diagnosis of severe mitral regurgitation. Cardiopulmonary revival was done by an emergent resuscitation for the ventricular fibrillation before admission. She had mild anoxic brain damage and brain magnetic resonance imaging (MRI) revealed severe brain atrophy. Chest X-ray showed severe cardiomegaly and congestion. Beating heart mitral valve replacement was planned for the prevention of reperfusion injury. A cardiopulmonary bypass was established by bicaval drainage and aortic return. The prolapse of anterior leaflet was recognized through transeptal approach after aortic clamp. We selected continuous infusion of antegrade cardioplegia for intraoperative coronary perfusion. Mitral valve replacement was done successfully. During intraoperation and postoperation, ventricular fibrillation did not occur. On-pump beating mitral valve replacement is a good procedure to prevent perioperative ventricular arrhythmia especially such the case with a decompressed myocardial function and with a preoperative episode of lethal ventricular arrhythmia necessary for cardiopulmonary resuscitation.

Developmental expression of endogenous oscillations and waves in the auditory cortex involves calcium, gap junctions, and GABA

Neuronal oscillations and population waves (OWs) may be important for the maturation of neural circuits in the cortex and other developing areas of the CNS. We examined endogenous network activity by whole-cell and paired extracellular recordings in the thalamorecipient auditory cortex (ACx) in slices of gerbil pups during the first three postnatal weeks. Separately, we examined network ensemble correlates of the OWs using population intracellular free calcium (Ca2+) imaging in slices bulk-loaded with fura-2 AM. In slices devoid of physiological or pharmacological manipulations, spontaneous multi-neuronal bursts recorded extracellularly at the perirhinal cortex precede bursts simultaneously recorded at the ACx, suggesting their caudorostral propagation. OWs waned after postnatal day (P) 7, ceased following hearing onset (P12), and accompanied altered membrane properties. Population imaging from P2-5 slices with fura-2 AM revealed endogenously generated waves that spread from the perirhinal cortex toward the thalamorecipient ACx. Wave incidence varied between 5 waves/min to 0.4 waves/min. OWs were disrupted by treatment of slices with [Ca2+]i chelator 1,2-bis(o-aminophenoxy)ethane-N,N,N',N'-tetraacetic acid, the gap junction blocker mefloquine or the GABAA receptor blocker bicuculline. These results suggest that propagating activity involving calcium, gap junctions and GABAergic transmission exists in the gerbil ACx and it correlates with key developmental events in vivo. We speculate such activity may be integral to postnatal maturation of ACx.

[Stenting for postoperative airway stenosis due to traumatic tracheobronchial rupture]

A 43-year-old man underwent repair for the broken trachea, left main bronchus and right main brouchus due to trauma. Twenty-seven months after the initial surgery, he developed dyspnea and required ventilatory support. Computed tomography showed severe stenosis of the left main bronchus, tracheomalasia and bronchomalasia of right main bronchus. A self-expandable metallic stent (SEMS) was placed in the bilateral main bronchus and T-tube in the trachea. SEMS developed granulatory and cicatricial stenosis of the airway, which caused severe dyspnea. Replacement of SEMS with Dumon stents was successfully done and dyspnea was disappeared. A silicon stent should be used for treating postreconstructive airway stenosis including tracheobronchomalasia.

Commissure holder: an innovative device for aortic valve-sparing technique

The key to obtaining maximal valve coaptation from the aortic valve-sparing procedure is in appreciating the optimal geometry of each component of the aortic root. We describe a new device called the Commissure Holder (patent pending) that aids in the selection of an appropriate graft size and in the determination of the optimal position at which each commissure should be sutured to the graft.

[Aortic root replacement after operation for the ascending aorta and/or aortic valve]

We reviewed ten cases who underwent aortic root replacement after operation for the ascending aorta and/or aortic valve. As initial operation, aortic valve replacement (AVR) was performed in five patients, replacement of the ascending aorta in two, original Bentall operation in two, and entry closure and suspension of the aortic valve in one. At reoperation, three patients were diagnosed as aneurysm of the ascending aorta, two were annulo-aortic ectasia, and one was acute aortic dissection, chronic dissecting aneusym, pseudoaneurysm of the ascending aorta, prosthetic valve endocarditis, and massive aortic regurgitation. Aortic root replacement was performed using mechanical valved composite graft in all cases. One patient who underwent repeat aortic root replacement for prosthetic valve endocarditis was died of septemia and ventricular fibrillation. Five patients had nine complications (two low output syndrome, respiratory failure and cerebral infarction, one gastrointestinal bleeding, septemia and ventricular fibrillation). In conclusion, aortic root replacement after operation for the ascending aorta and/or aortic valve was performed with acceptable morbidity and mortality.

Spontaneous rupture of the thoracic aorta

BACKGROUND

Spontaneous rupture of the thoracic aorta without trauma, aneurysm, or dissection is an extremely rare but catastrophic disorder. Two cases of spontaneous aortic rupture are presented, both treated surgically with satisfactory results.

METHODS

A review of the English literature found 16 patients with the diagnosis of spontaneous rupture of the thoracic aorta from 1961 through 1998. Eighteen reported cases, including the 2 cases presented herein, are reviewed.

RESULTS

The representative clinical picture is one of a middle-aged hypertensive patient with acute chest pain and collapse, with imaging modalities demonstrating hemopericardium, hemomediastinum, or hemothorax. According to the reported experiences, aortography was accurate for identifying the rupture site although the findings were sometimes subtle. Misdiagnosis or nonsurgical management resulted in the patient's death. All 8 patients who did not undergo aortic repair died within 3 weeks after the onset, whereas 9 of 10 patients who underwent surgical aortic repair survived.

CONCLUSIONS

For patients with a definitive or possible diagnosis of spontaneous rupture of the thoracic aorta, prompt operation is imperative through an optimal surgical approach to identify and repair the rupture site with appropriate circulatory support.

Pedicled pericardial flap for pulmonary artery in adult dogs

OBJECTIVE

Stenosis of extracardiac conduit after reconstruction of right ventricle outflow tract is a serious problem, and the purpose of this study was to identify the suitability of broadly pedicled autologous pericardial flap for the reconstruction of pulmonary artery trunk in adult dogs.

METHODS

Eight mongrel dogs had replacement of a pulmonary artery trunk with extracardiac conduit, in which prosthetic vascular graft formed the posterior wall and pedicled (group P, n = 5) or free (group F, n = 3) autologous pericardium created the anterior wall. Six months after the operation, pressure gradient across the conduit were measured and put to death for pathological examinations.

RESULTS

Pressure gradient across the conduit in groups F and P was 16.0 +/- 16.8 mmHg and 1.4 +/- 1.7 mmHg respectively. In the microscopic examination, flaps of group P had neo-intimal cells in the innermost layer, abundant cellular component with elastic fiber was seen within the middle layer, and collagen tissue within the outer layer. Conversely, the presence of calcification was shown within collagen fiber layer of all patches in group F. Sparse cellular component and the absence of neo-intimal cells were also observed in group F.

CONCLUSIONS

Broadly pedicled pericardial flap is more conceivable to prevent the development of conduit stenosis after right ventricle outflow tract reconstruction, if compared with free pericardial patches.

[Epidemiological and clinical aspects of snake bites in the municipalities of the state of Amazonas, Brazil]

In the State of Amazonas, accidents with snakes are a public health problem. For this reasons, the objective of this work was to carry out a descriptive study of the snake accidents attended in the health units of 34 municipalities, one district and two border platoons in the State of Amazonas. The characteristics most commonly observed among those involved in snake accidents were: farmers (50. 4%), male (81.3%), belonging to the working age-group (72.1%), bitten on an upper limb (88.5%) by a "jararaca" (48.6%) or a "surucucu" (46.8%) in the rural part of the municipality (70.2%). The local signs and symptoms most frequently observed in those who received medical care more than 6 hours after the accident (57.3%) were edema (76.9%), pain (68.7%), erithema (10.2%) and hemorrhage (9. 3%). The systemic manifestation most frequently observed was hemorrhage (18.8%). Serotherapy was administered in only 65.9% of patients, the intravenous route being the route most commonly used to administer the antivenin (52.3%), while other non- recommended routes were widely used. In the majority of patients the antivenin given was antibotropic. The most frequent complications were: abscess 13.7%, necrosis 12.3%, secondary infection 8.3%, renal insufficiency 2.5% and gangrene 2.5%. The medical procedures most used in the treatment of these complications were drainage 52.6%, debridement 28.9%, amputation 10.5%, surgical cleaning 5.3% and peritoneal dialysis 2.6%. The fatality rate was 1%.

Remnant omental transfer for the mediastinitis after coronary bypass surgery with right gastroepiploic artery

A one-stage procedure for the treatment of mediastinitis after coronary bypass surgery utilizing the right gastroepiploic artery is described. This procedure consists of thorough debridement of mediastinal pus and necrotic tissue, excision of infected sternal bone, mediastinal irrigation, and immediate transfer of the "remnant" omental pedicle based on the "left" gastroepiploic artery without postoperative drainage or irrigation. Recently, this procedure was applied to our patients followed by excellent results.

Expression of angiogenic factors in rabbit spinal cord after transient ischaemia

It is known that angiogenic factors are induced in brain by ischaemia, and new vessel formation is correlated with better prognosis in patients of stroke. However, the role of angiogenesis and expression of angiogenic factors in spinal cord ischaemia is uncertain. We here investigated expression of three highly potent angiogenic peptides, i.e. basic fibroblast growth factor (bFGF), vascular endothelial growth factor (VEGF), and hepatocyte growth factor (HGF) in the rabbit spinal cord after transient ischaemia, by Western blot and immunohistochemical analysis. Western blot analysis revealed that bFGF was induced at 8 h after transient ischaemia and decreased thereafter. Immunoreactive VEGF was also induced at 8 h, and it disappeared thereafter. HGF was not detected in the spinal cord with sham-operation or ischaemic injury. By immunohistochemical analysis, bFGF was weakly expressed in only a few small interneurons in sham-operated spinal cords. However, it was induced to a marked degree in motor neurons and interneurons of the anterior horn at 8 h after reperfusion. It was also induced in small neurons of the posterior horn. The expression in the anterior horn decayed thereafter though it lasted until 7 d in the posterior horn. VEGF was not expressed in sham-operated spinal cords, but the expression was induced in large motor neurons and interneurons at 8 h with marked reduction at 1 d. In contrast, HGF was not expressed in the spinal cord with sham-operation or ischaemic injury. These factors are known to play pivotal roles in angiogenesis, regulation of blood flow, and protection of endothelial cells. Through induction of these angiogenic peptides, protection of vascular endothelial cells and improvement of regional blood flow might be occurring in the spinal cord after ischaemia.

Brain damage after aortic arch repair using selective cerebral perfusion

BACKGROUND

Selective cerebral perfusion is one of the most popular methods for cerebral protection during aortic arch repair. However, causes of postoperative brain damage are not fully understood. We analyzed brain damage after aortic arch repair using selective cerebral perfusion for true aortic arch aneurysm in regard to preoperative cerebral infarction and intracranial and extracranial occlusive arterial disease.

METHODS

Over a 9-year period, 60 patients with true aortic arch aneurysm underwent aortic arch repair using selective cerebral perfusion. Postoperative brain damage was evaluated in regard to preoperative cerebral infarction detected by computed tomography, magnetic resonance imaging, or both in 50 patients and intracranial and extracranial occlusive arterial disease detected by digital subtraction angiography, magnetic resonance angiography, or both in 35 patients.

RESULTS

Seven (12%) of the 60 patients died within 30 days of operation. Postoperative brain damage occurred in 6 (10.5%) (3, coma, and 3, hemiplegia) of 57 patients; 3 patients who died without awakening were excluded. Preoperatively, old cerebral infarction was detected in 9 patients (18%), and silent cerebral infarction (lacunar infarction and leukoaraiosis) was diagnosed in 26 patients (52%). Postoperative brain damage occurred in 3 (33%) of the 9 patients with preoperative cerebral infarction and in 3 (23%) of 13 patients with negative preoperative brain findings; this excludes 2 patients who died without awakening. No patient with silent cerebral infarction had postoperative brain damage. Occlusive arterial disease was detected in 7 patients (20%). The incidence of brain damage in these patients was 71% (5/7), which was significantly greater than that of 4% (1/28) in patients without occlusive arterial disease (p < 0.001).

CONCLUSIONS

Silent cerebral infarction may not be a risk factor for postoperative brain damage. Preoperative evaluation of intracranial and extracranial occlusive arterial disease provides important information as to whether a patient might sustain brain damage after aortic arch repair using selective cerebral perfusion.

[Open distal anastomosis or aortic balloon occlusion technique during complete aortic arch replacement]

The technique of open distal anastomosis or application of aortic balloon occlusion catheter designed to occlude the descending thoracic aorta have been used in 33 and 19 patients, respectively, to control bleeding during the procedure of distal anastomosis for complete aortic arch replacement with a prosthetic graft. These two techniques allowed us a simple approach to the lesion and the avoidance of clamp injury to the fragile aortic tissue. Open distal anastomosis was applied for 91% patients of operated aortic dissection and all emergent cases, it's duration ranged from 10 to 110 minutes with an average of 58 minutes under 18.2 degrees C of lowest esophageal temperature. On the other hand, aortic occlusion balloon was inserted for mainly true aortic aneurysm patients without an emergency, and helped to maintain the perfusion pressure on a lower part of body around 50 mmHg by the 1550 ml/min in an average of perfusion flow femoral artery under 21.2 degrees C of temperature. The difference of postoperative renal and liver function evaluated by serum enzyme levels of total bilirubin, GOT, GPT, LDH, creatinine and BUN did not reach to statistical significance between the patients using open distal anastomosis and balloon occlusion, however, the incidence of postoperative complication including either renal, liver dysfunction, abdominal problem or paraplegia was significantly higher in the patient group with open distal technique. Either open distal anastomosis or aortic balloon occlusion technique would be appropriately selected according to the patient's characteristics or the condition of aortic disease to be operated.

Delayed selective motor neuron death and fas antigen induction after spinal cord ischemia in rabbits

The mechanism of spinal cord injury has been thought to be related with tissue ischemia, and spinal motor neuron cells are suggested to be vulnerable to ischemia. To evaluate the mechanism of such vulnerability of motor neurons, we attempted to make a reproducible model for spinal cord ischemia. Using this model, cell damage was histologically analyzed. Detection of ladders of oligonucleosomal DNA fragment was investigated with gel electrophoresis up to 7 days of the reperfusion. Time course expression of Fas antigen, identified as a apoptosis-regulating molecules, was also assessed in rabbit spinal cord following transient ischemia. Spinal cord sections from animals sacrificed at 8 h, 1 day, 2 days, and 7 days following 15-min ischemia were immunohistochemically evaluated using monoclonal antibodies for Fas antigen. Following 15-min ischemia, the majority of motor neuron showed selective cell death at 7 days of reperfusion. Typical ladders of oligonucleosomal DNA fragments were detected at 2 days of reperfusion. Immunoreactivity of Fas antigen were induced at 8 h to 1 day of reperfusion selectively in motor neuron cells. The expression of Fas antigen may be related to the activation of apoptosis signal in motor neuron cells after spinal cord ischemia in rabbits.

Delayed and selective motor neuron death after transient spinal cord ischemia: a role of apoptosis?

OBJECTIVE

The mechanism of spinal cord injury has been thought to be related to tissue ischemia, and spinal motor neuron cells are suggested to be vulnerable to ischemia. We hypothesized that delayed and selective motor neuron death is apoptosis.

METHODS

Thirty-seven Japanese domesticated white rabbits weighing 2 to 3 kg were used in this study and were divided into two subgroups: a 15-minute ischemia group and a sham control group. Animals were allowed to recover at ambient temperature and were killed at 8 hours, and 1, 2, 4, and 7 days after reperfusion (n = 3 at each time point). By means of this model, cell damage was histologically analyzed. Detection of ladders of oligonucleosomal DNA fragment was investigated with gel electrophoresis up to 7 days of the reperfusion. Immunocytochemistry, in situ terminal deoxynucleotidyl transferase-mediated deoxyuridine triphosphate-biotin nick-end labeling staining was also performed.

RESULTS

After 15 minutes of ischemia, most of the motor neurons showed selective cell death at 7 days of reperfusion. Typical ladders of oligonucleosomal DNA fragments were detected at 2 days of reperfusion. Immunocytochemistry showed in situ terminal deoxynucleotidyl transferase-mediated deoxyuridine triphosphate-biotin nick-end staining was detected at 2 days of reperfusion selectively in the nuclei of motor neurons.

CONCLUSION

These results suggest that delayed and selective death of the motor neuron cells after transient ischemia may not be necrotic but rather predominantly apoptotic.

Apoptosis of motor neurons with induction of caspases in the spinal cord after ischemia

BACKGROUND AND PURPOSE

Some neuronal subpopulations are especially vulnerable to ischemic injury. In the spinal cord, large motor neurons are vulnerable to ischemia and are selectively lost after transient ischemia. However, the mechanisms of the neuronal loss have been uncertain. We hypothesized that spinal motor neurons might be lost by apoptosis and investigated a possible mechanism of neuronal death by detection of double-strand breaks in genomic DNA and immunohistochemical analysis for caspases, ie, interleukin-1beta converting enzyme (ICE), Nedd-2, and CPP32.

METHODS

We used a rabbit spinal cord ischemia model created with a balloon catheter. The spinal cord was removed at 8 hours, 1, 2, or 7 days after 15 minutes of transient ischemia, and histological changes were studied with hematoxylin-eosin staining. To detect double-strand breaks in DNA, a staining with terminal deoxynucleotidyl transferase-mediated dUTP-biotin in situ nick end labeling (TUNEL) was performed. Furthermore, expression of ICE, Nedd-2, and CPP32 was investigated by Western blotting and immunohistochemical analysis.

RESULTS

Motor neurons were selectively lost at 7 days after transient ischemia. TUNEL study demonstrated that no cells were positively labeled until 1 day after ischemia, but nuclei of some motor neurons were positively labeled at 2 days. Western blot analysis revealed no immunoreactivity for ICE and slight immunoreactivities for Nedd-2 and CPP32 in the sham-operated spinal cords. However, immunoreactivity became apparent at 8 hours after transient ischemia, decreased at 1 day, and returned to baseline level at 2 days. Immunohistochemical analysis demonstrated that motor neurons were responsible for induction of those caspases.

CONCLUSIONS

Double-strand breaks in genomic DNA and induction of three caspases were demonstrated. These results indicate that motor neuron death in the spinal cord after transient ischemia is profoundly associated with activation of apoptotic processes.

Enhancement of heat shock protein expression after transient ischemia in the preconditioned spinal cord of rabbits

PURPOSE

This investigation was designed to evaluate the mechanism used to acquire a tolerance to spinal ischemia. We investigated inductions of the heat shock protein (HSP) 70 gene and protein in rabbit spinal cord with or without preconditioning.

METHODS

Neurologic function, morphologic changes, and inductions of HSP70 messenger RNA (mRNA) and protein were compared in the cases of a 15-minute ischemia 2 days after sham treatment and a 15-minute ischemia 2 days after 10-minute preconditioning.

RESULT

HSP70 mRNA was induced at 8 hours of reperfusion after a 15-minute ischemia 2 days after sham treatment. HSP70 protein was induced slightly in selective motor neuron cells at 8 hours of reperfusion, and about 70% of motor neuron cells showed selective cell death after 7 days of reperfusion (p < 0.01). On the other hand, large populations of the motor neuron cells survived at 7 days after the 15-minute ischemia that was applied at 2 days after preconditioning (p < 0.01). HSP70 mRNA was induced persistently as compared with the case of a 15-minute ischemia 2 days after sham treatment. The motor neuron cells strongly produced immunoreactive HSP70 from 8 hours to 2 days.

CONCLUSION

Preconditioning with 10-minute ischemia enhanced and prolonged the HSP70 gene expression at both mRNA and protein levels and saved the motor neuron cells from subsequent lethal ischemia. These changes of HSP70 gene expression may play an important role in the acquisition of ischemic tolerance of motor neuron cells in rabbit spinal cord.

Sutureless ringed graft replacement of descending thoracic aorta with extensive calcification

A 79-year-old hypertensive woman, with fusiform shaped atherosclerotic aneurysm in the descending thoracic aorta whose medial layer was maintained by an extensive solid calcium plate (porcelain aorta), was successfully treated using a sutureless intraluminal ringed graft. Spools of the ring were fixed by circumferential ligatures at both proximal and distal sites of anastomosis and a dilated segment of the aorta was replaced with the tube graft.

Replacement of the ascending aorta and aortic valve with a composite graft: operative and long-term results

The purpose of this study is to analyze our treatment experience on patients with ascending aortic aneurysms, with aortic regurgitation. From January 1974 to December 1995, 49 patients underwent replacement of the aortic valve and ascending aorta with a composite graft, in which primary operation cases were 44 and reoperation ones were 5. The Bentall technique was used in 20 patients, the button technique in 11, the interposition graft technique in 11, and a combination of the interposition graft and button technique in 7. All but one reoperation cases underwent the interposition graft technique. Hospital mortality was 30% for the Bentall technique, and 9.1% for the button technique and 9.1% for the interposition graft technique; there was no hospital mortality in the combination of the interposition graft and button technique. Hospital mortality of interposition graft technique in primary operation cases was 9.1%, and that in reoperation cases was 0%. Hospital mortality in patients underwent from 1974 to 1985 was 30.8%, 27.8% from 1986 to 1991, and 0% from 1992 to 1995. Five late deaths occurred in the Bentall group (35.7%) and one late death in the button technique (9.1%). Not late deaths in the other groups have occurred. In summary, operative mortality in Bentall technique group was higher than that of the other groups. Operative results were improved by the change of operative methods. The interposition graft technique is preferable for patients undergoing reoperation or when tension on the ostial anastomoses may occur. The button technique is best for patients with aortic dissection or inflammation involving the coronary ostia.

Successful management of left main bronchial stenosis as a rare complication of pericardiectomy

We present a rare complication of pericardiectomy and the effective management thereof. A 67-year-old female with dyspnea and upper abdominal pain was received at our department upon referral. Chest roentgenogram and cardiac catheterization preceded a diagnosis of constrictive pericarditis. Pericardiectomy was performed subordinate to median sternotomy and left anterolateral thoracotomy. Extubation was carried out on day 2 but reintubation was necessitated on the same day as a result of progressive dyspnea. Chest roentgenogram revealed an atelectasis of the left lung. Fiberoptic bronchoscopy showed left main bronchial stenosis resulting from a pulsating external structure. A postoperative computed tomogram substantiated the stenotic left main bronchus between the dilated left pulmonary artery and the thoracic descending aorta. An expandable metallic stent for the treatment of this complication was selected over other invasive procedures. Two years of follow-up reveal no complications. Accordingly, an expandable metallic stent has demonstrated its effectiveness not only on bronchial stenosis due to malignancy or tuberculosis but on benign cases such as this as well.

[Brain damage following aortic arch repair with regard to techniques of selective cerebral perfusion and preoperative cerebral lesions]

One hundred and twenty-nine aortic aneurysm patients (true 68 and dissection 61) underwent aortic arch repair from January 1987 to December 1995. Postoperative brain damage was evaluated regarding both preoperative brain lesions and techniques of selective cerebral perfusion (SCP) in that one pump for SCP until April 1992, then two pumps were employed, one for right and the other for left hemisphere of the brain. Overall hospital mortalities were 21% in true and 13% in dissecting aneurysms. Ten patients were complicated with postoperative brain damages (coma 8 and hemiplegia 2), registering 7.8% of total patients. Both history of stroke and silent cerebral infarction (SCI) detected by CT and/or MRI were considered to be positive in the mean of having preoperative brain lesions. Although there was no significant difference between incidences of postoperative brain damage in true and dissecting aneurysms, registering 11% and 4% respectively, preoperative brain lesions in true aneurysm (68%) was significantly greater than dissecting aneurysm (32%). Furthermore, the incidence of postoperative brain damage was 22% in one-pump SCP which was significantly greater than 3% in two-pumps SCP in the patients with a true aneurysm. But there was no postoperative brain complication in patients with SCI even using either one two pumps for SCP. The present data suggest two-pumps SCP is better technique for cerebral protection compared to one-pump SCP for aortic arch repair.