The first report of the thyroid function of haemophilic patients with HIV/HCV co-infection in Japan

INTRODUCTION

A high incidence of thyroid dysfunction is reported in patients with HIV or HCV mono-infection. We have conducted a periodic medical examination including the thyroid function for haemophilic patients with HIV/HCV co-infection due to contaminated blood products.

METHODS

We examined the thyroid function (as assessed by the FT3, FT4 and TSH levels) in 45 haemophilic patients, including thyroglobulin and auto-antibody, antithyroglobulin antibody, antithyroid peroxidase antibody and anti-TSH receptor antibody in 28 patients.

RESULTS

All the patients were males (median age: 42 years; range: 29-66). The median values of thyroid function were FT3 3.36 pg mL(-1) , FT4 1.125 ng mL(-1) and TSH 1.65 μIU mL(-1) . Five patients (11.1%) had high TSH levels. In 28 patients in whom the presence of auto-antibodies was examined, the median age was 47 years of age. The median value of thyroglobulin was 16 ng mL(-1) and two patients showed high levels of thyroglobulin. The presence of anti-TSH receptor antibody of all the patients was negative, but one patient (3.5%) was positive of antithyroid peroxidase antibody and antithyroglobulin antibody.

CONCLUSIONS

Since 0.68-3.6% of the general healthy population is reported to show hypothyroidism, our data showed that the proportion of hypothyroidism in haemophilic patients with HIV/HCV co-infection was more frequent than that of the normal population.

Evaluation of the operative methods for Graves' disease

AIM

In Japan, surgery for Graves' disease (GD), which is considered to be a radical therapy, has been restricted by various guidelines. Nevertheless, some patients benefit from surgery. We sought to identify a reasonable operative method for GD by comparing the efficacy and safety among patients undergoing different extents of thyroidectomy.

METHODS

A total of 162 patients underwent thyroidectomy for GD between 2003 and 2012 in our department. We compared the clinical factors among those who underwent subtotal thyroidectomy (ST), near-total thyroidectomy (NTT), and total thyroidectomy (TT).

RESULTS

The ST, NTT, and TT groups included 111, 21, and 30 patients, respectively. The patient sex, period between disease onset and surgery, and preoperative thyroidal function were not substantially different among the three groups. With regard to surgical variables, the duration of surgery, amount of blood loss, and postoperative length of hospitalization were not substantially different among the three groups. Postoperative recurrent laryngeal nerve (RLN) palsy was transient in all cases, but the rate was significantly higher in the TT group compared to the other two groups (P<0.001). The incidences of transient hypocalcemia and permanent hypoparathyroidism were not substantially different among the groups. The proportion of patients who required the postoperative administration of levothyroxine was significantly lower in the ST group compared to the TT and NTT groups. Hyperthyroidism recurrence was noted in eight patients in the ST group (7.2%).

CONCLUSION

NTT for GD is thus considered to be a reasonable operative method regarding both efficacy and safety.

[Metabolic syndrome]

About 20 years ago, Reaven presented the concept that a series of related factors such as hyperinsulinemia, hypertension, low high-density lipoprotein (HDL)-cholesterol levels, and hypertriglyceridemia tended to co-occur in the same individual and that this risk-factor clustering and its association with insulin resistance might be of critical importance in the underlying cause of cardiovascular disease. This risk-factor clustering called as "syndrome X" has now become "metabolic syndrome" (METS). Nowadays, METS is becoming well known as a condition of high-risk for the subsequent development of ischemic cardiovascular disease in Western population as well as Japanese population and it is proved that the prevalence of METS is very common. There are several different diagnostic definitions for METS. In Japanese definition, waist circumference is essential for criterion of METS because visceral fat accumulation is believed to be associated with METS more closely than the body mass index (BMI) itself or the amount of subcutaneous fat. Therefore treatment strategy to reduce visceral fat seems to be crucial for management of patients with METS. Adipose tissue is not simply an energy storage organ, but also a secretary organ, producing a variety of bioactive substances, including adiponectin. Adiponectin is paradoxically reduced in obesity and elevated adiponectin concentration is associated with greater insulin sensitivity. Therefore hypoadiponectinemia can be considered a key factor of the development of METS. We believe that detection, prevention and treatment of METS are important clinical and public health challenges.

Video-assisted subtotal or near-total thyroidectomy for Graves' disease

BACKGROUND

Surgery remains the treatment of choice for patients with Graves' disease. The purpose of the present study was to assess the usefulness and efficacy of video-assisted subtotal or near-total thyroidectomy in patients with Graves' disease.

METHODS

Between March 2000 and December 2004, 63 patients with Graves' disease underwent video-assisted subtotal, near-total or total thyroidectomy. Fifty-three patients (84 per cent) were considered for surgery after failure of antithyroid drug and radioiodine therapy, whereas the other ten patients were initially selected for surgical treatment based on their own preference. Treatment outcome was evaluated, including surgical complications, thyroid function, quality of life and patient satisfaction with the surgical result.

RESULTS

All patients were operated on using a video-assisted technique, with some modifications depending on time and experience. There were no conversions to open surgery. Three patients (5 per cent) had temporary recurrent laryngeal nerve palsy that recovered spontaneously. Most patients were satisfied with the surgical results, particularly regarding the placement of the surgical scars.

CONCLUSION

Video-assisted subtotal or near-total thyroidectomy is a safe and effective procedure for treatment of Graves' disease.

Expression of 11beta-hydroxysteroid dehydrogenases in bovine follicle and corpus luteum

In glucocorticoid target organs, local concentrations of active glucocorticoid are determined by the relative expression of two 11beta-hydroxysteroid dehydrogenases (HSDs): bi-directional 11beta-HSD type1 (11HSD1) that mainly activates cortisone to cortisol, and dehydrogenase 11beta-HSD type2 (11HSD2) that inactivates cortisol to cortisone. In this study, we examined the expression of mRNA encoding these two 11beta-HSDs in bovine granulosa cells harvested from preovulatory follicles and corpora lutea (CL). Ovaries were obtained from Holstein cows at a local slaughterhouse. Follicles larger than 10 mm in diameter and CL were dissected and follicular fluid and granulosa cells were taken. Corpora lutea were weighed and their stages were morphologically assessed (stage I, days 1-4; stage II, days 5-10; stage III, days 11-17; stage IV, days 8-20). Follicles were classified into four groups according to their hormonal status (oestradiol (E(2)): progesterone (P(4))>1: oestrogen active; E(2):P(4)<1: oestrogen inactive) and stage of the oestrous cycle (luteal or follicular phase). Total RNA was extracted with phenol-chloroform and subjected to a semi-quantitative RT-PCR for 11HSD1, 11HSD2 and beta-actin. Concentrations of steroids in follicular fluid were determined by an enzyme immunoassay. In granulosa cells, only 11HSD1 mRNA was detected. There was a negative correlation between the expression of 11HSD1 and the concentration of cortisol in follicular fluid (P<0.05), indicating 11HSD1 may act as a dehydrogenase in the bovine follicle. Both types of 11beta-HSDs were expressed in CL. The levels of mRNA for both isozymes were high in stage I and II, and were decreased in stage III CL. In stage IV CL, the expression of 11HSD2 but not 11HSD1 mRNA increased. These results indicate that the bovine granulosa cells and CL express 11HSD1 and 11HSD2, and they may play an important physiological role in the bovine ovary through modulating the local glucocorticoid environment.

Obstruction of St Jude medical valves in the aortic position: a consideration for pathogenic mechanism of prosthetic valve obstruction

Between 1995 and 2000, 8 patients with St. Jude Medical (SJM) valves in the aortic position required 9 redo valve replacement for prosthetic valve obstruction. Obstruction of the prosthetic valve was diagnosed by simultaneous echocardiography and cineradiography, and process of restricted leaflet movement that progressed to hemodynamic impairment was observed by serial studies in three recent patients. An oral anticoagulation was considered to be adequate in all patients except one patient who had withdrawal of warfrain. Pannus was the sole cause of valve obstruction in seven events in 6 patients, and both thrombus and pannus in 2 patients. Pannus overgrowth was found on the inflow aspect of the SJM valve, and involved the ends of the straight edge of the leaflets over pivot guards. These results suggest that pannus might play the primary role in development of obstruction of aortic SJM valves in patients on adequate oral anticoagulation.

High-dose cimetidine reduces proinflammatory reaction after cardiac surgery with cardiopulmonary bypass

BACKGROUND

Cimetidine, which is usually used for gastric ulcer, enhances cellular immunity. The effect of cimetidine on perioperative proinflammatory response after cardiac surgery with cardiopulmonary bypass was investigated.

METHODS

Elective coronary artery bypass graft cases in which CPB was performed were placed randomly in a cimetidine (C) group (n = 20) or a no-treatment (N) group (n = 20). The time course of plasma levels of neutrophil elastase, interleukin (IL)-6 and IL-8, leukocyte counts, lymphocyte recovery ratio, C-reactive protein, creatine-kinase-MB, and oxygenation index were analyzed.

RESULTS

The plasma levels of neutrophil elastase and IL-8 were inhibited in the C groups at 2 hours after CPB termination. In a comparison of the two groups, the C group demonstrated higher lymphocyte recovery ratio and lower C-reactive protein on postoperative day 5 and shorter intubation time. No intergroup differences were observed in IL-6, leukocyte counts, creatine-kinase-MB levels, or oxygenation index.

CONCLUSIONS

Cimetidine may reduce surgical stress and augment the immune system after cardiac surgery with cardiopulmonary bypass.

Molecular cloning and heterologous expression of novel glucosyltransferases from tobacco cultured cells that have broad substrate specificity and are induced by salicylic acid and auxin

Scopoletin is one of the phytoalexins in tobacco. Cells of the T-13 cell line (Nicotiana tabacum L. Bright Yellow) accumulate a large amount of scopoletin, also known as 7-hydroxy-6-methoxycoumarin, as a glucoconjugate, scopolin, in vacuoles. We report here the molecular cloning of glucosyltransferases that can catalyze the glucosylation of many kinds of secondary metabolites including scopoletin. Two cDNAs encoding glucosyltransferase (NtGT1a and NtGT1b) were isolated from a cDNA library derived from the tobacco T-13 cell line by screening with heterologous cDNAs as a probe. The deduced amino-acid sequences of NtGT1a and NtGT1b exhibited 92% identity with each other, approximately 20-50% identities with other reported glucosyltransferases. Heterologous expression of these genes in Escherichia coli showed that the recombinant enzymes had glucosylation activity against both flavonoids and coumarins. They also strongly reacted with 2-naphthol as a substrate. These recombinant enzymes can utilize UDP-glucose as the sugar donor, but they can also utilize UDP-xylose as a weak donor. RNA blot analysis showed that these genes are induced by salicylic acid and auxin, but the time course of the expression was different. This result is similar to the changes in scopoletin glucosylation activity in these tobacco cells after addition of these plant growth regulators. These results might suggest that one of the roles of the products of these genes is scopoletin glucosylation, in response to salicylic acid and/or auxin, together with the other glucosyltransferases in tobacco cells.

Analysis of Tag1-like elements in Arabidopsis thaliana and their distribution in other plants

Analysis of genomic DNA of Arabidopsis Columbia (Col.) ecotype using a transposon Tag1-specific primer showed the presence of Tag1 homologues which was confirmed by Southern hybridization with a Tag1 probe. Further analysis showed that the homologue, 0.75 kb in length, had inverted repeats at both ends, 8-bp duplicated sequences at the site at which it is located and about 80% homology with Tag1, and was randomly distributed in the Arabidopsis genome. Based on these results, we concluded that these elements are non-autonomous variants of Tag1 and we termed this element sTag1. Using the polymerase chain reaction fragment hybridization technique, we found the distribution of such homologues in other plant species.

Repair of left ventricular rupture following mitral valve replacement concomitant with left atrial reduction procedure--intracardiac patch and extracardiac buttress suture

Rupture of the posterior wall of the left ventricle after mitral valve replacement is a dire complication associated with a very high mortality. This study reports a successful repair of type I left ventricular rupture, which occurred after mitral valve replacement concomitant with a left atrial reduction procedure, by combination of an intracardiac patch and an extracardiac buttress suture. In a case such as this, in which hemostasis is quite difficult to establish, this combination technique is particularly effective.

Antiinflammatory effects of colforsin daropate hydrochloride, a novel water-soluble forskolin derivative

BACKGROUND

To evaluate the effects of colforsin daropate hydrochloride (colforsin), a water-soluble forskolin derivative, on hemodynamics and systemic inflammatory response after cardiopulmonary bypass, we conducted a prospective randomized study.

METHODS

Twenty-nine patients undergoing coronary artery bypass grafting were randomized to receive either colforsin treatment (colforsin; n = 14) or no colforsin treatment (control; n = 15). Administration of colforsin (0.5 microg.kg(-1).min(-1)) was started after induction of anesthesia and was continued for 6 hours. Perioperative cytokine and cyclic adenosine monophosphate levels, hemodynamics, and respiratory function were measured serially.

RESULTS

Marked positive inotropic and vasodilatory effects were observed in patients receiving colforsin. Interleukin 1beta, interleukin 6, and interleukin 8 levels after cardiopulmonary bypass were significantly (p < 0.05) lower in the colforsin group. Plasma levels of cyclic adenosine monophosphate increased significantly (p < 0.05) in the colforsin group, and the levels correlated inversely (r = -0.56, p = 0.002) with the respiratory index after cardiopulmonary bypass.

CONCLUSIONS

Intraoperative administration of colforsin daropate hydrochloride had potent inotropic and vasodilatory activity and attenuated cytokine production and respiratory dysfunction after cardiopulmonary bypass. The results indicate that the technique can be a novel therapeutic strategy for the systemic inflammatory response associated with cardiopulmonary bypass.

A study on the role of platelet function in patients with chronic pulmonary thromboembolism

There has been no study on the platelet function in the patient with chronic pulmonary thromboembolism (CPTE). We speculate that the platelet function may be elevated in the patients.

PURPOSE

1. The platelet functions were compared among CPTE before surgery, deep vein thrombosis (DVT) and normal adult people. 2. The severity of CPTE in clinical grading to the platelet functions were compared. 3. The platelet function were compared before and after pulmonary thromboendarterectomy.

METHODS

Pre-opetative CPTE group (n=16), post-operative CPTE group (n=11), DVT group (n=9) and control group (normal adult people: n=33) were investigated on the platelet functions defined as platelet adhesion (AD) and platelet aggregation (AG) test in this study.

RESULTS

1. No activation of platelet functions was observed in pre-operative CPTE patients. 2. There was no apparent relationship between the severity of disease and platelet functions. 3. Significant elevation of AG was obtained in the patients who received pulmonary thromboendarterectomy.

CONCLUSION

In consideration to the finding in postoperative study, the administration of anti-platelet drug will help to prevent re-thrombosis of the pulmonary arteries after surgery.

[Effects of colforsin daropate hydrochloride in patients undergoing coronary artery bypass surgery]

The effects of Adehl, colforsin daropate hydrochloride, on hemodynamics were studied in patients undergoing cardiac surgery. Twenty-six patients who underwent coronary artery bypass grafting were divided into two groups according to the intraoperative administration of Adehl. The control group (n = 14) received no Adehl treatment and the Adehl group (n = 12) received Adehl infusion immediately after anesthesia induction (0.5 microgram.kg-1.min-1) for 6 hours. Hemodynamic measurements and clinical results were accessed perioperatively. The Adehl group resulted in significantly (p < 0.05) lower pulmonary capillary wedge pressure and systemic vascular resistance, and significantly (p < 0.05) greater cardiac indices and left ventricular stroke work indices than those in the control group. No significant difference was found in the rate pressure product between the groups. The Adehl group resulted in significantly shorter duration of intubation and ICU stay. Adehl was not associated with a significant increase in the prevalence of adverse effects. The results suggest that Adehl has positive inotropic and vasodilator effects without increasing myocardial oxygen consumption. Thus, it is suggested that Adehl can be a useful agent for the perioperative management in patients undergoing cardiac surgery.

Differences in management and outcomes of acute myocardial infarction among four general hospitals in Japan

OBJECTIVE

To ascertain the differences among hospitals in Japan in the management patterns and outcomes of patients with acute myocardial infarction (AMI).

DESIGN

Retrospective cohort study by means of patient chart review.

SETTING

Four tertiary-care teaching hospitals in Japan observed over a 1-year period.

STUDY PARTICIPANTS

Consecutive patients (N=482) admitted for AMI.

MAIN OUTCOME MEASURES

Clinical characteristics, rates of diagnostic and therapeutic procedures performed, cardiac complications, and length of stay.

RESULTS

Patients' clinical characteristics differed significantly among the four hospitals in terms of age, gender, and prior cardiac history, but not in terms of comorbidity or infarct location. The frequency and type of diagnostic and therapeutic procedures were different, and in-hospital mortality varied (4-14%, P=0.022). Average length of hospital stay ranged from 15.8+/-12.6 days to 41.0+/-19.4 days (P=0.0001). After adjustment for the clinical characteristics, these differences remained significant among hospitals.

CONCLUSION

Considerable differences in the management and outcomes of patients with AMI exist in Japan.

Surgical treatment of prosthetic valve endocarditis with left ventricular-aortic discontinuity: reconstruction of the left ventricular outflow tract with a xenopericardial conduit

BACKGROUND AND AIM OF THE STUDY

Aortic prosthetic valve endocarditis (PVE) with annular destruction presents a challenge that requires techniques to eradicate the infection and correct the hemodynamic abnormality.

METHODS

Between July 1, 1996 and March 31, 2000, six patients with native or PVE of the aortic valve and aortic annular destruction underwent surgical treatment. Of these patients, three (two men, one woman; mean age 71.0 years) had circumferential annular destruction of the aortic annulus, and formed the basis of this study. The microorganisms responsible for the infection were Streptococcus spp. in two patients and Staphylococcus aureus in one patient. In addition to aggressive debridement of the infected tissue, repair was achieved by reconstruction of the left ventricular outflow tract with a xenopericardial conduit and fixation of the new prosthetic valve to the conduit.

RESULTS

One patient with ventricular septal perforation, multiple systemic embolism and sepsis died of low cardiac output syndrome soon after surgery. Two operative survivors were followed up for 9 and 51 months, with no late deaths. No patient has experienced recurrent infection, pericardial patch aneurysm, or prosthetic valve detachment.

CONCLUSION

These operative procedures provide easy and secure fixation of the pericardial patch to the healthy tissue under excellent operative view, as well as a sturdy structure for the fixation of the new prosthesis, and complete exclusion of the abscess cavity from the blood stream.

Triple valve replacement with bileaflet mechanical valves: is the mechanical valve the proper choice for the tricuspid position?

A more durable mechanical valve may be a better choice for the tricuspid position than a bioprosthesis when the patient already has mechanical prosthesis in the left side of the heart. Eleven cases of triple valve replacement (total follow-up period, 49.5 patient years), all with mechanical valves, are reviewed to assess optimal valve selection. Nine patients had undergone a total of 12 previous cardiac surgeries. Three patients died in hospital (27.3%), but there were no late deaths among the survivors. Two cases of valve thrombosis in the tricuspid position occurred (linearized incidence: 4.04%/patient years) and 1 of these required reoperation. Because of this high incidence of valve thrombosis, the bileaflet mechanical valve is not considered to be the best choice. Even if mechanical valves are implanted in the left side of the heart, a bioprosthesis may be a better choice at the tricuspid position.

Plant hormone regulation on scopoletin metabolism from culture medium into tobacco cells

Tobacco (Nicotiana tabacum L. Bright Yellow) T-13 cell line has an ability for production of scopoletin. In this cell culture, scopoletin is taken up from culture medium and accumulated in vacuoles after conversion to scopolin when cells are treated with 2,4-dichlorophenoxyacetic acid (2,4-D) (Taguchi et al. (2000)). To clarify the effect of 2,4-D on tobacco cells, its interaction with several other plant hormones was investigated. Other auxins also stimulated the uptake in the same manner as 2,4-D did, although higher concentrations were required than that of 2,4-D. When p-chlorophenoxyisobutyric acid (PCIB), an antiauxin, was added to the cell culture before 2,4-D, it inhibited 2,4-D-stimulated scopoletin uptake. This result suggests that the stimulation of scopoletin uptake was one of the auxin effects on tobacco cells. Among other classes of plant hormones that were tested, only salicylic acid stimulated the uptake. When these hormones were added to the cell cultures before 2,4-D, methyl jasmonate and kinetin reduced scopoletin uptake. These results suggest that this scopoletin uptake by tobacco cells is regulated by the interaction between different plant hormones.

Coronary artery bypass grafting in patients with mild renal insufficiency

It is well known that dialysis-dependent renal failure increases the likelihood of a poor outcome following cardiac surgery. However, it is not known whether non-dialysis-dependent mild renal insufficiency also influences clinical outcome. Fifty-five patients with non-dialysis-dependent renal insufficiency undergoing coronary artery bypass grafting (CABG) (Renal group: serum creatinine level >1.5 mg/dl) were enrolled. These patients were then matched on prognostic variables to 148 patients with normal renal function (

CONTROL GROUP

serum creatinine level <1.5 mg/dl). The early postoperative clinical results showed that patients in the Renal group were more likely to develop postoperative renal failure (18% vs 1%: p=0.0002) and hemorrhage requiring re-exploration (11% vs 2%; p=0.01). Total morbidity was significantly higher in the Renal group (40% vs 22%; p=0.01). Multivariate analysis revealed that the Renal group was the second most important predictor of morbidity (odds ratio (OR) =2.2) behind left ventricular dysfunction (OR=2.9). The Renal group was also the second most important predictor of postoperative renal failure (OR=12.5). Therefore, non-dialysis-dependent mild renal insufficiency also increases the risk of morbidity following CABG.

Internal thoracic artery as a collateral source to the ischemic lower extremity

Based on the superior long-term results, internal thoracic artery is widely used for coronary artery bypass grafting. However, the vessel can play an important role as a collateral source to the chronically ischemic lower limbs. We reported two cases who underwent simultaneous revascularization to the myocardium and lower limbs because this particular condition was anticipated. Selective angiography of internal thoracic artery was useful to determine its role before harvesting in our cases. Careful preoperative examinations and choice of surgical approach are required for such patients to avoid serious vascular complications.

Effects of intraoperative administration of atrial natriuretic peptide

BACKGROUND

Biological activity of endogenous atrial natriuretic peptide (ANP) may decrease during cardiopulmonary bypass. To evaluate the effects of intraoperative administration of exogenous ANP in patients undergoing cardiopulmonary bypass, we conducted a prospective randomized study.

METHODS

Eighteen patients undergoing mitral valve surgery were randomized to receive either ANP treatment (ANP group; n = 9) or no ANP treatment (control group; n = 9). Atrial natriuretic peptide was given immediately after initiation of cardiopulmonary bypass for 6 hours (0.05 microg x kg(-1) x min(-1)). Plasma ANP, brain natriuretic peptide and cyclic guanosine monophosphate (cGMP) levels, hemodynamic variables and renal function were assessed perioperatively.

RESULTS

Administration of ANP increased plasma cyclic guanosine monophosphate levels, urine output and fractional sodium excretion, and decreased preload, afterload and plasma brain natriuretic peptide levels significantly (p < 0.05). Plasma cyclic guanosine monophosphate levels correlated with plasma ANP levels (r = 0.95, p = 0.0001), correlated with fractional sodium excretion (r = 0.53, p = 0.02), and correlated inversely with systemic vascular resistance (r = -0.54, p = 0.02).

CONCLUSIONS

Intraoperative administration of ANP had potent effects on natriuresis and systemic vasodilation by elevating cyclic guanosine monophosphate levels. The results suggest that the technique is useful for the management of hemodynamics and water-sodium retention after cardiopulmonary bypass.

Biological activity of endogenous atrial natriuretic peptide during cardiopulmonary bypass

To evaluate the effect of cardiopulmonary bypass (CPB) on atrial natriuretic peptide (ANP) biological activity in patients undergoing cardiac operations, we conducted a prospective study. Ten patients undergoing mitral valve surgery were enrolled. Plasma levels of ANP and cyclic guanosine monophosphate (cGMP), hemodynamic variables, and renal function parameters were assessed perioperatively. The molar ratio of cGMP to ANP (as a marker for ANP biological activity) decreased significantly (p < 0.05) during CPB despite similar plasma ANP levels. The ratio correlated inversely with the duration of CPB (r = -0.85, p = 0.002). The ratio also correlated with fractional sodium excretion (r = 0.65, p = 0.04) and correlated inversely with pulmonary vascular resistance (r = -0.79, p = 0.009) and atrial filling pressure (r = -0.84, p= 0.003) postoperatively. CPB decreased the molar ratio of cGMP to ANP, which may represent ANP biological activity, such as vasodilation and natriuresis. The phenomenon may contribute to water-sodium retention and pulmonary hypertension after cardiac surgery.

Coronary artery bypass surgery in a patient with myasthenia gravis

A 73-year-old man with myasthenia gravis required quadruple coronary artery bypass grafting due to triple-vessel disease. Anesthetic management was performed with general anesthesia using a reduced dose of muscle relaxant with the aid of a neuromuscular transmission monitor. He was extubated 14 hrs after surgery without difficulty under this monitor. His postoperative course was uneventful. A patient with myasthenia gravis who required coronary artery bypass surgery was successfully performed by the deliberate preoperative evaluation of patient's myasthenic and cardiac status, and by the careful perioperative management.

Purification and characterization of UDP-glucose: hydroxycoumarin 7-O-glucosyltransferase, with broad substrate specificity from tobacco cultured cells

The enzyme UDP-glucose: hydroxycoumarin 7-O-glucosyltransferase (CGTase), which catalyzes the formation of scopolin from scopoletin, was purified approximately 1200-fold from a culture of 2,4-D-treated tobacco cells (Nicotiana tabacum L. cv. Bright Yellow T-13) with a yield of 7%. Purification to apparent homogeneity, as judged by SDS-PAGE, was achieved by sequential anion-exchange chromatography, hydroxyapatite chromatography, gel filtration, a second round of anion-exchange chromatography, and affinity chromatography on UDP-glucuronic acid agarose. The purified enzyme had a pH optimum of 7.5, an isoelectric point (pI) of 5.0, and a molecular mass of 49 kDa. The enzyme did not require metal cofactors for activity. Its activity was inhibited by Zn(2+), Co(2+) and Cu(2+) ions, as well as by SH-blocking reagents. The K(m) values for UDP-glucose, scopoletin and esculetin were 43, 150 and 25 µM, respectively. A study of the initial rate of the reaction suggested that the reaction proceeded via a sequential mechanism. The purified enzyme preferred hydroxycoumarins as substrates but also exhibited significant activity with flavonoids. A database search using the amino terminus amino acid sequence of CGTase revealed strong homology to the amino acid sequences of other glucosyltransferases in plants.

Effects of angiotensin-converting enzyme inhibitor during warm blood cardioplegia

BACKGROUND

Effects of captopril, an angiotensin-converting enzyme inhibitor, during warm blood cardioplegia were assessed in the blood-perfused, isolated rat heart.

METHODS

The isolated hearts were arrested for 60 minutes with warm blood cardioplegia given at 20-minute intervals and were reperfused for 60 minutes. The control group (n = 10) received standard cardioplegia and the captopril group (n = 10) received cardioplegia supplemented with captopril (2 mmol/L). Cardiac function, myocardial metabolism, and cardiac release of circulating adhesion molecules were assessed before and after cardioplegic arrest.

RESULTS

Left ventricular end-diastolic pressure and -dp/dt were significantly (p<0.05) lower and coronary blood flow was significantly (p<0.05) greater in the captopril group than the control group during reperfusion. The captopril group resulted in significantly (p<0.05) less cardiac release of lactate, thiobarbituric acid reactive substances during reperfusion. Cardiac release of intercellular adhesion molecule-1 was significantly (p<0.05) less in the captopril group at 60 minutes of reperfusion.

CONCLUSIONS

The results suggest that supplementation of captopril during warm blood cardioplegia provides superior myocardial protection by suppressing lipid peroxidation and leukocyte-endothelial cell interaction during reperfusion.

Biocompatibility of heparin-coated extracorporeal bypass circuits: new heparin bonded bioline system

Biocompatibility of a new type of heparin-coated cardiopulmonary bypass equipment, the Bioline, was evaluated in coronary artery bypass surgery cases. The heparin-coated (H) group (n = 15; Quadrox Bioline oxygenator/reservior and Carmeda BioMedicus BP-80 centrifugal pump) was compared with the nonheparin-coated (N) group (n = 12; uncoated, otherwise similar oxygenator, centrifugal pump, tubing, and filter set). Both groups used full systemic heparinization. The peak values of neutrophil elastase, C3a, IL-6, and IL-8 at 2 h after cardiopulmonary bypass (CPB), and C3a levels at the end of CPB and at 2 h after CPB were significantly reduced in the H group compared with those of the N group. However, no statistically significant intergroup differences were observed in thrombin-antithrombin complex, D-dimer, beta-thromboglobulin, or platelet factor-4. No significant differences were observed in hemostasis time, postoperative 12 h blood loss, required amount of blood transfusion, or intubation time. In conclusion, the Bioline demonstrated partially improved biocompatibility, in terms of leukocyte and complement activation, and proinflammatory cytokine production. However, it did not improve platelet activation, coagulation, or fibrinolysis cascade under full systemic heparinization. As a result, the clinical beneficial impact seemed to be the minimum.

Obstruction of St Jude Medical valves in the aortic position: significance of a combination of cineradiography and echocardiography

BACKGROUND

Obstruction of the St Jude Medical valve (St Jude Medical, Inc, St Paul, Minn) is a rare but serious complication.

METHODS

Cineradiographic and echocardiographic evaluations of aortic St Jude Medical valves were simultaneously performed on 54 patients, with no signs of prosthetic valve dysfunction late after surgery.

RESULTS

Although closing angles of the leaflets corresponded closely with the manufacturer data, restricted opening of the leaflets (opening angle >/= 20 degrees ) was found in 16 (group D) of the 54 patients by means of cineradiography. The opening angles were equal to or less than 14 degrees in the other 23 patients (group N) and between 15 degrees and 19 degrees in the remaining 15 (group M). Doppler-derived transprosthetic pressure gradients were significantly higher (P =.03) and the velocity index was significantly lower (P =.003) in group D than in group N. However, no significant differences were found in those values between group N and group M. Replacement of the aortic St Jude Medical valves was performed in 5 of the 16 patients, and the remaining 11 have been followed up because of relatively low pressure gradients. The cause of restricted leaflet movement was pannus formation without thrombosis in 4 patients and valve thrombosis with pannus formation in one.

CONCLUSIONS

Reduced valve orifice area and restricted opening of the leaflets resulting from excess growth of pannus probably led to obstruction of the aortic St Jude Medical valves. A combination of cineradiography and echocardiography makes it possible to provide an accurate and detailed diagnosis of obstruction of the valve.

Plasma exchange for hyperbilirubinemia following implantation of a left ventricle assist system: a case report

A 49-year-old patient with end-stage dilated cardiomyopathy underwent implantation of a left ventricular assist system (LVAS). Although the systemic circulation seemed to be improved, the serum total bilirubin (Tbili) level increased sharply in the early postoperative period (preoperative Tbili, 5.7 mg/dl; postoperative day 3, 33.6 mg/dl). Plasma exchange (PE) was performed 7 times from postoperative day 4, and the Tbili level decreased to 16.3 mg/dl by postoperative day 11. Thereafter, serum Tbili normalized concomitant with improved circulatory condition. The cause of the hyperbilirubinemia was considered to be temporary right ventricular dysfunction or hepatic sinusoid endothelial dysfunction. The liver function was recoverable, so PE had been effective in this case. Unfortunately, the patient suffered a midbrain infarction and ultimately died. From this experience, PE is recommended if it is judged that liver function can be preserved and circulation is adequate, but its implementation should not be delayed. It is essential that LVAS is implanted before damage occurs to end-organ function and thus prevent hyperbilirubinemia.

ATS prosthetic valve motion: an in vitro analysis

BACKGROUND AND AIM OF THE STUDY

We have reported clinical findings that normally functioning open pivot ATS valves did not open completely. In order to analyze features of the ATS valve motion more precisely, in vitro tests were conducted.

METHODS

Opening angles and pressure gradients of the ATS valve were measured and compared with those of the St. Jude Medical (SJM) valve under steady flow, but with various outlet configurations. Second, opening angles of the two valves were measured under pulsatile conditions in two different outflow configurations: (i) a 'straight outlet' where the leaflets did not extend into the tapering outflow chamber, and (ii) an 'abrupt enlargement outlet' where the leaflets extended directly into the enlarged outflow space. Third, flow visualization studies were made under steady flow conditions in the straight and abrupt enlargement outlet conduits, respectively.

RESULTS

Under steady flow conditions, opening of the ATS valve was restricted in most outflow configurations; only when the outlet angle was 0 degrees did the valve open fully. The SJM valve opened completely in all downstream configurations. Despite restricted opening in the ATS valve, the pressure gradient was similar in both valves. Under pulsatile conditions, both valves opened fully in the straight outlet; however, in the abrupt enlargement outlet the ATS valve opened incompletely and the SJM valve completely. Substantial turbulent flow was observed at the outside of the leaflet and corners of the conduit, notably with the ATS valve.

CONCLUSION

This study showed that the ATS valve did not open fully except when the outflow was straight, and the leaflet did not extend into an enlarged downstream chamber. Structural features of the ATS, such as its axis being located close to the straight edge and its leaflets extending further downstream from the ring orifice, may cause this unique valve behavior.

[A case study of alpha feto protein (AFP)-producing gastric carcinoma with multiple liver metastases, in which chemotherapy was effective enough to once save a life in rapid decline]

A 57 year-old man visited our hospital with general fatigue and a sensation of abdominal fullness. He had lost 10 kg in body weight during the previous 3 months. Between admission and the time the diagnosis of AFP-producing gastric carcinoma with multiple liver metastases was made, his condition deteriorated quickly due to the rapid growth of the liver metastases. Combined chemotherapy consisting of cisplatin and 5-FU was given, and was so effective that the patient recovered well and both serum AFP level and the size of the swollen liver decreased markedly. However, about a month after being discharged, he experienced a relapse and was readmitted. After obtaining informed consent, chemotherapy consisting of methotrexate and 5-FU was started. Though the level of tumor markers and LDH decreased significantly, he died of hepatic failure. We think that this case is worthy of notice because it shows the effectiveness and limitations of chemotherapy in a situation where the condition of a patient is deteriorating quickly due to rapid extension of an AFP-producing gastric carcinoma.

A case report of surgical treatment of quadricuspid aortic valve associated with regurgitation

A case of a 65-year-old woman who had a quadricuspid aortic valve associated with aortic regurgitation is reported. The patient had severe aortic regurgitation and four equally divided aortic cusps. The valve abnormality was detected by a transesophageal echo and an aortography. The incomplete aortic valve was excised and replaced by a St. Jude Medical prosthesis. Although this case had no coronary abnormality, a coronary displacement is often reported in quadricuspid aortic valve cases. In order to perform an operation safely, accurate information which is obtained by a non-invasive examination of the transesoph-ageal echo is quite valuable as it can indicate the need for further preoperative examinations of the coronary arteries.

Scopoletin uptake from culture medium and accumulation in the vacuoles after conversion to scopolin in 2,4-D-treated tobacco cells

Tobacco (Nicotiana tabacum L. Bright Yellow) T-13 cell line has the ability to produce scopoletin endogenously and release some of it into the culture medium. We investigated the mechanism of scopoletin uptake following treatment of a tobacco culture with 2,4-dichlorophenoxyacetic acid (2,4-D). Addition of [14C]-labeled scopoletin showed that scopoletin was taken up by 2,4-D-treated cells and converted to scopolin, a 7-O-glucoside of scopoletin. This uptake of scopoletin began 6 h after 2,4-D addition to the cells. Experiments using several inhibitors showed that this uptake was energy-dependent. The phenomenon of 2,4-D-stimulated uptake was observed only for 7-hydroxycoumarins, such as scopoletin, umbelliferone and esculetin. To further investigate the site for scopoletin accumulation, we separated the vacuoles from T-13 cells and quantified the coumarin contents in this fraction. Most of the scopoletin in the vacuoles was present as glucoconjugate, scopolin. Moreover, glucosylation activity was absent from isolated vacuoles and, therefore, is likely to be located in the cytosol. Therefore, we can state that 2,4-D treatment of tobacco cells stimulated scopoletin uptake. The scopoletin was converted into scopolin in the cytoplasm, and then transferred into the vacuoles.

Effects of supplemental L-arginine during warm blood cardioplegia

OBJECTIVES

Effects of supplemental L-arginine, nitric oxide precursor, during warm blood cardioplegia were assessed in the blood perfused isolated rat heart.

METHODS

The isolated hearts were perfused with blood at 37 degrees C from a support rat. After 20 minutes of aerobic perfusion, the hearts were arrested for 60 minutes with warm blood cardioplegia given at 20-minute intervals. This was followed by 60 minutes of reperfusion. The hearts were divided into the following three groups according to the supplemental drugs added to the cardioplegic solution. The control group (n = 10) received standard warm blood cardioplegia. The L-ARG group (n = 10) received warm blood cardioplegia supplemented with L-arginine (3 mmol/l). The L-NAME group (n = 10) received warm blood cardioplegia supplemented with L-arginine (3 mmol/l) and L-nitro-arginine methyl ester, a competitive inhibitor of nitric oxide synthase (1 mmol/l). After 60 minutes of cardioplegic arrest, cardiac function, myocardial metabolism and myocardial release of circulating adhesion molecules were measured during reperfusion.

RESULTS

Left ventricular end-diastolic pressure was significantly lower (p<0.05) in the L-ARG group than in the control group and the L-NAME group during reperfusion. Isovolumic left ventricular developed pressure, dp/dt and coronary blood flow were significantly greater (p< 0.05) in the L-ARG group during reperfusion. The L-ARG group resulted in early recovery of lactate metabolism during reperfusion. Myocardial release of circulating intercellular adhesion molecule-1 (ICAM-1) and E-selectin were significantly less (p<0.05) in the L-ARG group at 15 minutes of reperfusion.

CONCLUSIONS

The results suggest that augmented nitric oxide by adding L-arginine to warm blood cardioplegia can preserve left ventricular function and ameliorate endothelial inflammation. The technique can be a novel cardioprotective strategy in patients undergoing cardiac surgery.

Plasma and urinary levels of heart fatty acid-binding protein in patients undergoing cardiac surgery

To evaluate the clinical significance of the plasma and urinary levels of heart fatty acid-binding protein (H-FABP) in patients undergoing cardiac surgery, a prospective study was conducted. Ten patients undergoing coronary artery bypass grafting were enrolled. Blood samples for determination of plasma H-FABP (pH-FABP), the MB isoenzyme of creatine kinase (CK-MB) and troponin-T (TnT), and urine samples for determination of urinary H-FABP (uH-FABP) were collected serially. None of the patients had perioperative myocardial infarction. The time to reach the peak level after aortic declamping was significantly (p<0.05) shorter for pH-FABP (1.4+/-0.5 h) than for CK-MB (2.5+/-0.5 h), TnT (6.6+/-1.3 h) or uH-FABP (3.0+/-0.6 h). Peak levels of pH-FABP correlated with those of CK-MB (r = 0.51, p = 0.04), TnT (r = 0.60, p = 0.03) and uH-FABP (r = 0.61, p = 0.03), and peak levels of uH-FABP correlated with CK-MB (r = 0.57, p = 0.04). Postoperative uH-FABP levels correlated inversely with the left ventricular stroke work index (r = -0.63, p = 0.04). This study demonstrated that H-FABP appears rapidly in plasma after reperfusion and reaches its peak earlier than other available biochemical markers; it appears also in urine and the levels correlated with cardiac function. Plasma and urinary H-FABP may be an early and sensitive biochemical marker for the diagnosis of myocardial injury in patients undergoing cardiac surgery.

Hypofibrinogenemia associated with a heterozygous missense mutation gamma153Cys to arg (Matsumoto IV): in vitro expression demonstrates defective secretion of the variant fibrinogen

We genetically analyzed a case of hypofibrinogenemia that showed no bleeding or thrombotic tendency. Direct sequencing of a polymerase chain reaction-amplified gamma-chain gene segment showed a novel nucleotide substitution. This heterozygous mutation encodes both Cys (TGT) and Arg (CGT) at residue 153. To examine the basis for the fibrinogen deficiency, we prepared expression vectors containing mutant gamma-chain DNAs encoding gamma153R and gamma153A for in vitro expression in Chinese hamster ovary (CHO) cells. Enzyme-linked immunosorbent assay and immunoblot analysis of the culture media and cell lysates showed that CHO cells transfected with gamma153R or gamma153A synthesized the variant gamma-chain, but did not secrete variant fibrinogen into the culture medium. Metabolic pulse-chase experiments showed that fibrinogen assembly was impaired when either variant gamma-chain was expressed. In cells expressing normal fibrinogen, assem- bly intermediates and intact fibrinogen were seen in cell lysates prepared after short (3 minutes) or long (1 hour) incubation with (35)S-methionine. Neither intermediates nor intact fibrinogen was seen with the variant gamma-chains. These data suggest that gamma-chains have an important early role in fibrinogen assembly. Thus, our results support the model for fibrinogen assembly proposed by Huang et al (J Biol Chem 268:8919, 1993), in which the first step in assembly is the formation of alphagamma or betagamma dimers, or both. This model implies that gammaCys153 has a critical role in the formation of these early assembly intermediates. We concluded that the gamma153Cys-->Arg substitution does not allow fibrinogen assembly and secretion, and this is manifest in vivo as a fibrinogen deficiency. We designated this variant as fibrinogen Matsumoto IV.

[Influence of milrinone on internal mammary artery grafts]

To evaluate the effects of milrinone on blood flow in the left internal mammary artery (LIMA) grafts and hemodynamic variables, we conducted a prospective randomized study. Twenty-four patients undergoing coronary artery bypass grafting were randomized to receive milrinone treatment (Milrinone; n = 12) or no milrinone treatment (Control; n = 12). Milrinone was given after induction of anesthesia at a speed of 0.5 microgram/kg/min for 24 hours. After start of cardiopulmonary bypass (CPB), CPB perfusion flow was adjusted to 2.4 l/m2 and LIMA blood flow was measured. Blood samples for determination of plasma cAMP levels were collected and hemodynamic measurements were also assessed perioperatively. LIMA blood flow was significantly greater in Milrinone than that in Control (40 +/- 4 vs 29 +/- 4 ml/min/m2, p < 0.05). Plasma levels of cAMP were significantly (p < 0.05) greater in Milrinone than those in Control at tha start of CPB (18 +/- 1 vs 13 +/- 1 pmol/ml) and at the end of CPB (24 +/- 2 vs 17 +/- 2 pmol/ml). Systemic vascular resistance was significantly (p < 0.05) lower and cardiac index was significantly (p < 0.05) greater in Milrinone than those in Control postoperatively. With its positive inotropic and systemic vasodilator activities, milrinone may have direct vasodilator effect on LIMA.

Aortic valve replacement for aortic regurgitation caused by aortitis

Between January 1984 and December 1998, 19 patients (16 with Takayasu's arteritis, 3 with non-Takayasu's aortitis) underwent surgical treatment for aortic regurgitation resulting from the aortitis. Of the 19 patients, 14 had aortic valve replacement (AVR) and 5 had aortic root replacement. One patient (5.3%) died of graft infection during the hospital stay. During the follow-up period, 1 (5.6%) of the 18 postoperative patients died of paravalvular leakage due to valve detachment, which also required redo-operations in 2 patients with non-Takayasu's aortitis. Both patients were operated on during the active phase of the inflammation without perioperative steroid therapy. Although transmural pledgeted sutures were used for replacement of the detached prosthetic valve in 1 of these 2 patients, disruption of the aortic wall resulted in recurrence of valve detachment. In the other patient, aortic root replacement was successfully performed with the Cabrol technique in the second operation. Perioperaitve steroid therapy plays an important role in preventing complications after AVR when the valve replacement is carried out during the active phase of the inflammation, and for patients with non-Takayasu's aortitis, aortic root replacement should be considered to reduce the tension on the suture line and the native aortic valve annulus.

Inhibitory effect of milrinone on cytokine production after cardiopulmonary bypass

BACKGROUND

It has been suggested that cyclic adenosine monophosphate-elevating agents suppress cytokine production. To evaluate the effects of milrinone, a phosphodiesterase III inhibitor, on cytokine production after cardiopulmonary bypass, we conducted a prospective randomized study.

METHODS

Twenty-four patients undergoing coronary artery bypass grafting were randomized to receive either milrinone treatment (milrinone, n = 12) or no milrinone treatment (control, n = 12). Administration of milrinone (0.5 microg x kg(-1) x min(-1)) was started after induction of anesthesia and was continued for 24 hours. Blood samples for determination of plasma cyclic adenosine monophosphate, tumor necrosis factor-alpha, interleukin-1beta, interleukin-6, and interleukin-8 levels were collected perioperatively.

RESULTS

No significant differences were observed in tumor necrosis factor-alpha and interleukin-8 levels between the groups. Interleukin-1beta and interleukin-6 levels after cardiopulmonary bypass were significantly (p < 0.05) lower in the milrinone group than in the control group. Plasma levels of cyclic adenosine monophosphate increased significantly (p < 0.05) after the administration of milrinone and the levels correlated inversely (r = -0.55, p < 0.01) with interleukin-6 levels.

CONCLUSIONS

The results indicate that milrinone suppresses cytokine production by elevating cyclic adenosine monophosphate levels in patients undergoing cardiopulmonary bypass. With its positive inotropic and vasodilator activities, milrinone may have antiinflammatory effects.

Surgical treatment of a coronary artery fistula with concomitant saccular coronary artery aneurysm: a case report

An extremely rare case of a coronary artery fistula with a concomitant saccular aneurysm is presented. A 65-year-old woman, who had a history of chest bruising 5 years earlier, suffered from chest pain, which was diagnosed as being due to left coronary artery-pulmonary artery fistulae concomitant with a giant saccular coronary artery aneurysm. Suture closure of the afferent coronary artery to the aneurysm, aneurysmorrhaphy, and transpulmonary closure of coronary artery-pulmonary artery fistulae were performed. The postoperative course was uneventful and the patient was well at 3 months after the operation. Because the risk of surgery appears to be less than the potential development of fatal complications, it is recommended for the treatment of coronary artery fistula with a concomitant saccular aneurysm.

Recovery from lymphocytopenia following extracorporeal circulation: simple indicator to assess surgical stress

This study investigated whether the lymphocyte count is a useful indicator to assess surgical damage following extracorporeal bypass. In Study 1, to investigate the correlation between extracorporeal circulating time (ECCT) and lymphocyte counts, 40 elective CABG patients were studied retrospectively. The lymphocyte recovery ratio (LRR), which represented the actual lymphocyte count divided by the preoperative lymphocyte count, was determined preoperatively, and on postoperative day (POD) 1, POD 3, and POD 5. In Study 2, the correlation between the interleukin-8 (IL-8) level and LRR was examined prospectively in elective CABG patients (n = 20). We measured the LRR and serum IL-8 levels preoperatively and during extracorporeal circulation (ECC) at 5 min, at the end of ECC, and 1, 3, and 12 h following ECC termination. Study 1 showed that the LRR decreased until POD 1 and gradually increased thereafter. The LRR had a negative correlation with the ECCT. In Study 2, the IL-8 level demonstrated a time course opposite to that of the LRR; it increased until 3 h after ECC termination and declined thereafter. There was a significant negative correlation between the LRR on POD 3 and the IL-8 level at 3 h after ECC termination. In summary, long-term ECC induced significant and prolonged lymphocytopenia. The LRR had a negative correlation with IL-8. These results indicated that the LRR may represent the degree of surgical stress following ECC; therefore, the counting of lymphocytes can be a quite useful bedside monitor to assess surgical damage and prognosis.

Constrictive pericarditis following hemopericardium due to ascending aortic dissection: A case report

A 79-year-old woman, who had had no history of trauma, tuberculosis, or collagen diseases, was referred for examination of general fatigue and shortness of breath on exertion. Physical examination revealed engorged neck veins, hepatomegaly, and ascites with abdominal distention. On chest x-ray the cardiac shadow was slightly enlarged and bilateral pleural effusion was present. An electrocardiogram showed low voltage of the QRS complex. Computed tomographic scans revealed two lumens in the remarkably dilated ascending aorta and the severely thickened pericardium. Cardiac catheterization showed elevated right atrial pressure and elevated right and left ventricular end-diastolic pressures, in addition to a pressure record of early diastolic dip and end-systolic plateau in the right ventricle. Aortography demonstrated aortic dissection localized to the ascending aorta. On the basis of these findings, the diagnosis of chronic ascending aortic dissection complicated with constrictive pericarditis was made. After subtotal pericardiectomy, graft replacement of the ascending aorta and proximal aortic arch was performed with successful results. Her postoperative recovery was uneventful. Histological studies of the pericardium showed fibrosis and marked infiltration of the inflammatory cells. No findings of specific pericarditis such as tuberculosis or collagen diseases were detected.

Morphology and histology of human and canine internal thoracic arteries

BACKGROUND

We evaluated human and canine internal thoracic arteries (ITAs) to determine whether the latter is valid for studies relevant to clinical use.

METHODS

We studied 19 human ITAs obtained from 1 female and 14 male victims of recent fatal accidents who had no evidence of cardiovascular disease (mean age = 39+/-19 years; range = 15 to 79 years), and ITAs of 21 randomly-selected mongrel dogs of both sexes, weighing 18-40 kg (average = 24.3+/-5.7 kg). Specimens were fixed in formalin at a controlled pressure of 120 mm Hg, before extensive assessment that included intimal thickening, condition of the internal elastic lamina, and number of medial elastic lamellae and vasa vasorum.

RESULTS

The canine morphology and histology were similar to the human ITAs, but there was no intimal hyperplasia, and the media and adventitia were thinner (ITAs of humans older than 40 years had significant increases in medial thickness, as well as in overall length). Morphologically and histologically, the left and right canine ITAs were almost completely the same.

CONCLUSIONS

Canine ITAs are valid for bilateral comparative studies and are a useful tissue source and model for clinically-relevant experimental studies.

A successful case of pulmonary thromboendarterectomy for chronic thromboembolic pulmonary hypertension with a thrombus in the right ventricle

Chronic thromboembolism is a frequent cause of progressive hypertension and carries a poor prognosis. Medical treatment is not effective and surgery provides the only potential for a cure at present. We herein report a successful case of thromboendarterectomy treated via a median sternotomy with intermittent circulatory arrest. A 43-year-old man was admitted to our hospital complaining of progressive dyspnea, edema of the lower extremities, and a fever with an unknown origin. A subsequent definitive evaluation showed him to be suffering from surgically accessible chronic thromboembolic pulmonary hypertension with a thrombus in the right ventricle. He underwent a pulmonary thromboendarterectomy and thrombectomy via a median sternotomy with intermittent circulatory arrest on November 24, 1994. Postoperatively he showed a marked improvement in his hemodynamic status and blood gas analysis. He has also returned to work with no trouble. Deep vein thrombosis appeared to be the pathogenesis of this case, but we could not find the origin of his unknown fever. He is currently being controlled by treatment with methylprednisolone as before.

Effects of the lipopolysaccharide-protein complex and crude capsular antigens of Pasteurella multocida serotype A on antibody responses and delayed type hypersensitivity responses in the chicken

The effects of the lipopolysaccharide-protein complex (LPS) and crude capsular antigen (CCA) prepared from Pasteurella multocida serotype A isolated from a duck in the Philippines, on antibody responses to sheep red blood cells (SRBC) and Brucella abortus (BA) and delayed type hypersensitivity (DTH) responses to bovine serum albumin (BSA) in the chickens were studied. Chickens injected subcutaneously with LPS and CCA at 1 and 2 weeks of age and immunized intravenously with the mixed antigens of SRBC and BA, at 3 and 4 weeks of age showed significantly increased antibody responses against both SRBC and BA, when evaluated at 7 days after each immunization. In addition, these chickens sensitized intramuscularly with the emulsion of BSA in complete Freund's adjuvant at 5 weeks of age, and then injected into the wattle with BSA at 7 weeks of age also showed significantly increased DTH responses against BSA, when evaluated at 24 and 48 hr after challenge. These results indicate that LPS and CCA of P. multocida serotype A have a property enhancing humoral and cell-mediated immune responses.