A case of effective intravenous methylprednisolone pulse therapy against severe COVID-19 infection after arteriovenous graft surgery

Perioperative COVID-19 infections in patients suffering from end-stage renal disease (ESRD) are more likely to become severe, with a high mortality rate, than those in other patients. For such patients, corticosteroid therapy is one of the limited number of treatment options. We experienced a case of ESRD in which COVID-19 infection immediately followed arteriovenous graft surgery. Although the respiratory condition deteriorated following dexamethasone administration, requiring invasive mechanical ventilation, intravenous methylprednisolone pulse therapy (pulse therapy) improved it dramatically, suggesting that pulse therapy may be effective against severe COVID-19 infection in patients suffering from ESRD.

[Accessory Mitral Valve Tissue Combined with Double-orifice Mitral Valve in an Elderly Patient:Report of a Case]

A 73-year-old man underwent echocardiography in order to assess any cardiac risk prior to surgery for renal cancer, and a large mobile mass was incidentally identified in his left ventricular outflow tract. Since a metastatic cardiac tumor was suspected, surgical resection of the mass was performed under cardiopulmonary bypass and hypothermic circulatory arrest. The mass had peduncles in the anterior leaflet of the mitral valve, the interventricular septum, and the papillary muscles. They were carefully removed by approaching through the aortic valve, and macroscopically suspected to be accessory mitral valve tissue. We observed the mitral valve via a transseptal approach to assess the function of the mitral valve and, as a result, a double-orifice mitral valve was identified. We should bear in mind that asymptomatic accessory mitral valve tissue can sometimes be detected in elderly patients, and is commonly associated with other congenital cardiac anomalies.

Analysis of reactive oxygen metabolites (ROMs) after cardiovascular surgery as a marker of oxidative stress

The transient systemic low perfusion that occurs during cardiovascular surgery leads to oxidative stress and the production of free radicals. A systemic increase of various markers of oxidative stress has been shown to occur during cardiopulmonary bypass (CPB). However, these markers have not been adequately evaluated because they seem to be reactive and short-lived. Here, oxidative stress was measured using the free radical analytical system (FRAS 4) assessing the derivatives of reactive oxygen metabolites (d-ROMs) and biological antioxidant potential (BAP). Blood samples were taken from 21 patients undergoing elective cardiovascular surgery. CPB was used in 15 patients, and abdominal aortic aneurysm (AAA) surgery without CPB was performed in 6. Measurements of d-ROMs and BAP were taken before surgery, 1 day, 1 week, and 2 weeks after surgery, and oxidative stress was evaluated. The d-ROM level increased gradually after cardiovascular surgery up to 2 weeks. Over time, the d-ROM level after surgery involving CPB became higher than that after AAA surgery. This difference reached statistical significance at 1 week and lasted to 2 weeks. The prolongation of CPB was prone to elevate the d-ROM level whereas the duration of the aortic clamp in AAA surgery had no relation to the d-ROM level. The BAP was also elevated after surgery, and was positively correlated with the level of d-ROMs. In this study, patients who underwent cardiovascular surgery involving CPB had significant oxidative damage. The production of ROMs was shown to depend on the duration of CPB. Damage can be reduced if CPB is avoided. When CPB must be used, shortening the CPB time may be effective in reducing oxidative stress.

Age-related Changes in Tongue Pressure during Swallowing

Although swallowing movement is known to change with aging, age-related differences in the tongue pressure for propelling a bolus from the oral cavity into the pharynx have yet to be investigated in a physiological condition. We hypothesized that tongue pressure during swallowing changed with aging and, using a 0.1-mm-thick sensor sheet with 5 measuring points, measured it while a 15-mL quantity of water was swallowed by young and elderly dentate individuals. Both groups showed a similar order of tongue pressure production at each point. However, the elderly group showed longer duration at each point, lower maximal magnitude in the anterio-median part of the hard palate, and higher magnitude in the circumferential parts of the hard palate than the young group. These results provide the first quantitative evidence of the age-related changes in tongue movement during natural swallowing, which could be attributed to muscle weakening and morphological changes in the oropharynx.

Direct measurement of nitric oxide during experimental cardiopulmonary bypass

We developed a system to measure nitric oxide (NO) concentration during cardiopulmonary bypass in anaesthetized pigs (n = 6). A T-shaped connector, attached to an NO sensor, was mounted in the extracorporeal circuit at two measuring sites: proximal to the membrane oxygenator (venous side) and distal to the arterial line filter (arterial side). After performing a preliminary validation study, we measured plasma NO concentration before and during total cardiopulmonary bypass circulation (non-pulsatile flow 1.5 l/min) and without pulmonary ventilation. After establishing bypass, PaO2 was 318 - 393 mmHg; when PaO2 was decreased to 80 - 100 mmHg, plasma NO concentration in the arterial circuit fell by 39.2 +/- 15.6 nM. There was no observable change in plasma NO concentration at the venous circuit. This new system could be useful in monitoring NO concentration during cardiac surgery with cardiopulmonary bypass, and for understanding the possible pathophysiological roles of hyper-nitric oxaemia in cardiopulmonary bypass-related cardiovascular complications.

Glucosylceramide accumulates preferentially in lamellar bodies in differentiated keratinocytes

BACKGROUND

Sphingolipids, e.g. ceramide (Cer), glucosylceramide (GlcCer) and sphingomyelin (SM), are important bulk constituents of plasma membranes in mammalian cells. In addition, these lipids are also enriched in certain intracellular organelles, as well as in the epidermal lamellar bodies (LBs) of differentiating keratinocytes (KCs). Epidermal Cer, which comprises a heterogeneous family of at least 10 members, is a key component of the stratum corneum (SC) lipids, and regulates permeability barrier function. Levels of GlcCer, but not SM, significantly increase during epidermal differentiation, and then both GlcCer and SM are enzymatically hydrolysed to Cer at and just above the transition from the stratum granulosum to the SC.

OBJECTIVES

To determine: (i) whether the GlcCer contained in different pools, i.e. the membrane fraction or the LB fraction, has different metabolic fates; and (ii) whether specific molecular species of GlcCer localize to distinct subcellular pools.

METHODS

To study the metabolic fate of specific molecular fractions of GlcCer and Cer, we first ascertained the full spectrum of molecular species present in cultured normal human KCs (CHK) in a differentiated condition as shown in vivo in epidermis. Cer species were analysed in CHK using matrix-assisted laser desorption/ionization time-of-flight mass spectrometry. Next, the metabolic fate of the GlcCer was studied by pulse-labelling of CHK with L-[14C]-serine.

RESULTS

The GlcCer of undifferentiated KCs comprised GlcCer B and Cer NS (or Cer 2), which contain nonhydroxy fatty acid (FA) as the amide-linked FA, while differentiated KCs displayed further heterogeneity of both GlcCer and Cer, including the presence of acylGlcCer and acylCer. The metabolic fates of these sphingolipids were determined. The GlcCer B level decreased over 2 days and then plateaued between days 3 and 5 following pulse-labelling of sphingolipids for 24 h. As GlcCer B declined, Cer NS (Cer 2) increased in a similar time-dependent manner. In contrast, both acylGlcCer and acylCer increased continuously in parallel over this experimental period.

CONCLUSIONS

Distinct GlcCer pools segregated to those that were either hydrolysable or nonhydrolysable in differentiated KCs. We assume that the latter pool appears to be LB enriched, and also sequestrates acylGlcCer from other cellular membrane fractions.

β2-Adrenergic Receptor Stimulation-Induced Immunosuppressive Effects Possibly through Down-Regulation of Co-Stimulatory Molecules, ICAM-1, CD40 and CD14 on Monocytes

We examined the effects of β2-adrenergic receptor (β2-AR) agonists on the expression of co-stimulatory molecules on lipopoly-saccharide (LPS)-stimulated human peripheral blood mononuclear cells. The study found that β2-AR agonists inhibited the expression of intercellular adhesion molecule-1 (ICAM-1), CD40 and CD14 on monocytes, and that AR agonist activity was antagonized by the selective β2-AR antagonist, butoxamine. The selective β2-AR agonists salbutamol and terbutaline induced a similar co-stimulatory molecule expression pattern. The LPS-induced production of tumour necrosis factor-α was inhibited by AR agonists, and this was also antagonized by butoxamine, and mimicked by salbutamol and terbutaline. The AR agonists also inhibited T-cell proliferation through β2-AR stimulation. This study clearly demonstrated that endogenous catecholamines elicited immunosuppressive effects through β2-AR stimulation, possibly due to down-regulation of the expression of ICAM-1, CD40 and CD14 on monocytes. These results suggested that the sympathetic nervous system might regulate the T-helper cell balance via the peripheral end-effectors of the stress system.

[Surgical treatment of thymic carcinomas]

Five cases of surgically treated thymic carcinoma are reported. The patients (4 men and a woman) ranged in age from 46 to 76 years old with a mean of 64.6. Four patients were asymptomatic and an abnormal shadow on X-ray films was noted. One remaining patient suffered from hoarseness. One patient had stage II disease and the others had stage III. Surgical tumor resection was performed in all cases. Only 1 patient among the 5 underwent a successful complete resection. Histological examinations of the resected specimens revealed squamous cell carcinoma of thymus. Four specimens were poorly differentiated and 1 is moderately differentiated carcinoma. All patients received radiation therapy post operatively. Three patients are alive without any recurrence 6, 8 and 109 months after the surgery. Thymic carcinomas are frequently invasive or metastatic at the time of diagnosis. But poorly differentiated group, in squamous cell carcinoma, mucoepidermoid carcinoma and besaloid carcinoma, are characterized by a low incidence of local recurrence and distant metastasis. They also have a good sensitivity for the radiation. Therefore complete surgical resection combined with postoperative radiation therapy should be a choice in treating thymic carcinomas. We considered that complete resection and postoperative radiation therapy is a curative therapy for thymic carcinomas.

Platelet activity of residual blood remained in the cardiopulmonary bypass circuit after cardiac surgery

AIM

We measured the platelet count and platelet function in residual blood in the cardiopulmonary bypass (CPB) circuit after cpb and compared them with data before CPB operation.

METHODS

The subjects included 34 cases of patients subjected to CPB surgery. The residual blood was concentrated by ultrafiltration after CPB, collected in the bag and the platelet count and platelet activity was measured. ADP 2, 5, 10 microM was used as agonists and measurement was made by turbidimetry.

RESULTS

The mean value of the platelet count was 18.3+/-5.65x10(4)/mm(3) before surgery and 17.2+/-8.39x10(4)/mm(3) in the residual blood, there is no difference. Concerning the platelet aggregation activity, the maximum aggregation rate decreased significantly with ADP 2 microM from 47.4+/-19.6% before surgery to 27.1+/-17.2% in the residual blood (p<0.01). Likewise, it decreased significantly with ADP 5 and 10 microM. The reduction rate of the platelet aggregation activity was higher in the group of not less than 100 minutes compared with the group of less than 100 minutes, but no significant difference was found.

CONCLUSION

Autotransfusing whole blood per se without the "cell saver" treatment is more advantageous to keep hemostasis function after surgery since many platelets having the aggregation activity exist in residual blood in the CPB circuit.

[Ventricular free wall re-rupture after surgical treatment of ventricular free wall rupture due to acute myocardial infarction; report of a case]

An in-hospital 72-year-old male with complaint of anterior chest pain was presented with shock. Pericardial effusion was confirmed by echocardiography, and therefore, he was brought to the operating room immediately with diagnosis of ventricular free wall rupture. The repair was performed using fibrin glue, fibrin sheet, and pericardial patch. His post-operative course was uneventful until massive bleeding came through the chest tube on the 5th day from the initial surgery. The emergency sternotomy was made again for hemostasis. In the re-operation, an approximately 20 mm laceration along the proximal circumflex artery was found and this was successfully repaired with 2 pledgetted horizontal mattress sutures. It is important and necessary to treat a postoperative patient taking care of re-rupture.

Late aortic root redissection following surgical treatment for acute type A aortic dissection using Gelatin-Resorcin-Formalin glue

OBJECTIVES

Although Gelatin-Resorcin-Formalin (GRF) glue is widely used in surgery for acute aortic dissection, late complications possibly due to the glue, such as late aortic root redissection, have also been reported. We have experienced similar complications, some of which required redo surgeries, and these cases are reviewed.

METHODS

Twenty-six consecutive patients who underwent surgery for acute type A aortic dissection using GRF glue, from December 1996 to February 2001, were retrospectively studied, with a special focus on any late complications and any reoperation.

RESULTS

Of the 21 patients who survived and were followed as outpatients, false aneurysms were found in 5 patients (21%) at 24-42 (mean 34) months following the initial surgery. Of these, 2 patients required resternotomy because of the increasing aneurysm diameter. In both cases, the aortic root was redissected at the site of the GRF glue use where the anastomosis between the aortic root and the prosthesis had widely opened and had become the aneurysm entry point. Significant aortic regurgitation was noticed in 3 patients (14%, 1 of whom showed a false aneurysm), and 2 of these underwent reoperation for aortic root redissection.

CONCLUSIONS

A high incidence of aortic root redissection with false aneurysm and/or aortic insufficiency was found following the surgery for acute aortic dissection using GRF glue. These patients should be carefully followed for years after surgery.

Portal and mesenteric vein and inferior vena cava thrombosis associated with antiphospholipid syndrome

We report a 48-year-old man with thrombosis of the portal and superior mesenteric vein and inferior vena cava associated with primary antiphospholipid syndrome (APS). Primary APS was diagnosed by a positive reaction with anticardiolipin antibody (aCL) and the absence of any evidence suggesting the presence of other disease states known to be associated with aCL. A coeliac angiography showed obstruction of the portal and superior mesenteric vein with prominent collaterals and cavernous transformation. Femoral vein angiography showed total obstruction of the external iliac vein and inferior vena cava, and dilation of the pelvic veins, with contrast medium in the lumbar vein. This case is noteworthy as a report of primary APS accompanied by extensive abdominal and pelvic venous thrombosis.

An outbreak of allergy-like food poisoning

Eight cases of allergy-like food poisoning resulting from the ingestion of yellowfin tuna, which had been kept in stock for 10 days prior to being cooked, are described. The main symptoms were headaches, facial flushing and palpitation. Samples of the ingested fish were analyzed for histamine content, and a high level of histamine was confirmed (310 mg/100 g of fish). Corticosteroids were given to 3 patients who exhibited dyspnea or persistent symptoms, while the remaining patients improved without medication. In situations where allergy-like clinical features are present after the ingestion of food, the possibility of allergy-like food poisoning should be recognized and included in a differential diagnosis.

Epidermal sphingomyelins are precursors for selected stratum corneum ceramides

Epidermal ceramides (Cer) comprise a heterogeneous family of seven species, including two unique omega-hydroxylated Cer, that are key components of the stratum corneum (SC) intercellular lamellar membranes responsible for the epidermal permeability barrier. Although both glucosylceramide (GlcCer) and the phospho-sphingolipid sphingomyelin (SM) are potential precursors of SC Cer, based on reported chemical structures of epidermal GlcCer and SC Cer, it is assumed that all major subfractions of SC Cer are generated from lamellar body-derived GlcCer. Yet, we and others have shown that SM-derived Cer are required for normal barrier homeostasis. Moreover, two pools of SM, one from plasma membrane, the other from lamellar body-derived contents, are potentially available for Cer production. To clarify the role of SM as a potential precursor of bulk or specific SC Cer, we compared Cer moieties in epidermal SM, Cer generated from epidermal SM by sphingomyelinase treatment, Cer within SC, and Cer that persist in Gaucher SC, where GlcCer cannot generate Cer due to an absence of beta-glucocerebrosidase. Using gas chromatography-mass spectrometry, fast atom bombardment-mass spectrometry, and nuclear magnetic resonance for Cer characterization, epidermal SM comprise three major subfractions with distinctive amide-linked (N-acyl) fatty acid (FA) compositions: that is, either long-chain FA (SM-1; C(22;-26)), short-chain FA (SM-2; primarily C(16)), and short-chain alpha-hydroxy FA (SM-3; C(16;-18)). In contrast, only trace quantities of omega-hydroxy FA were present. For each SM subfraction, the sphingoid base was either sphingosine or sphinganine, but phytosphingosine was not detected. Comparison of these SM with corresponding sphingomyelinase-generated epidermal Cer and SC Cer revealed that the Cer moieties of SM-1 and SM-3 are equivalent to Cer 2 (NS) and Cer 5 (AS), respectively. Moreover, both Cer 2 and Cer 5 occurred in Gaucher SC, whereas other Cer subfractions did not occur. These results indicate that two epidermal SM, that is, SM-1 and SM-3, are important precursors of two corresponding Cer in mammalian SC, that is, Cer 2 and Cer 5, but other Cer species, including the omega-hydroxy Cer species, do not derive from SM.

[A case of non-small-cell lung cancer successfully treated using combination chemotherapy with CDDP and vinorelbine]

A 67-year-old woman presented to our hospital with a chief complaint of bloody sputum. A plain chest X-ray a CT scan revealed a tumor shadow 3 cm in size in the middle lobe of the right lung, multiple nodular shadows in the bilateral lung fields and enlarged hilar and mediastinal lymph nodes. A tumor biopsy done under bronchoscopy revealed poorly differentiated adenocarcinoma of the lungs (cT2N3M1). She was given two courses of combination therapy consisting of cisplatin (80 mg/m2) and vinorelbine (20 mg/m2). The primary tumor in the middle lobe of the right lung and the lung metastases were markedly reduced in size, and a complete response was obtained. The only adverse events were grade 4 neutropenia and grade 2 nausea and vomiting.

[A case report of aneurysm of the ductus arteriosus combined with mitral regurgitation]

A case with the giant aneurysm of the ductus arteriosus combined with severe mitral regurgitation is reported. 58-year-old male underwent MVR and patch closure of the ductal orifice for staged operation. The first operation was MVR and patch closure of the PDA orifice of the pulmonary artery end using retrograde cerebral perfusion (RCP) with deep hypothermic circulatory arrest (DHC). The second operation was performed on 3 months after the first operation using left thoracotomy approach, and patch closure of the ductal orifice via the aorta using RCP with DHC was performed. Upon following-up examination, the patient is now doing well 20 months after the initial surgery.

[Combined valvular and coronary artery surgery]

Between 1990 and 1999, 78 patients underwent combined valvular coronary artery operation. Aortic valve disease was present in 49 patients, mitral valve disease in 23 patients, aortic and mitral valve disease in 6 patients. The average age was 67 years. Twelve patients had had a previous myocardial infarction. The average number of grafts inserted was 1.82 per patients, and the average number of artery grafts inserted was 0.96 per patients. The most number of grafts were placed prior to valve replacement or plasty. And periods of myocardial ischemia were kept at a minimum by coronary perfusion through free grafts. Preoperative mortality was 1.3%. And event fee ratio after operation was 95% (mean follow up 42 month). Therefore the operative risk of combined surgery is, in general, low and the long term results are favorable.

[Surgical treatment of intracardiac tumors in 25 patients]

For most intracardiac tumors, operation is the only means of therapy. In our institute, we have aggressively performed operation for intracardiac tumors regardless of histological type because resection for tumor had a beneficial effect on the hemodynamics with congestive heart failure. Twenty-five cases of cardiac tumors were operated upon from 1980 through 1998. The follow-up period ranged from 2 months to 19 years. The histological diagnoses of the tumors were as follows: benign tumors 24 (myxoma 21, papillary fibroelastoma 1, fibroma 1, angiomyolipoma 1) and malignant tumor (angiosarcoma 1). There was one hospital death in this series. In the New York Heart Association classification, the cardiac performances of intracardiac benign tumors after operation were Class I or II. The results of surgical treatment of intracardiac benign tumors were satisfactory both in short-term and in long-term. On the other hand the long term result of malignant tumor was extremely poor. A patient with angiosarcoma died 8 months later due to bone metastasis.

[Clinical study of emergency coronary artery bypass surgery]

Between January, 1996 and December, 1998, 29 patients were undergone emergency coronary artery bypass grafting (CABG) in our institute. Age ranged 34 to 85 years (mean 65 +/- 11 years, male:female = 25:4). Of 29 emergency cases, 3 were hospital death. Hospital mortality rate was 10.7%, which was significantly higher than the hospital mortality of elective CABG (1.4%) during the same period. The necessity of IABP before CABG was 72% in emergency cases (elective surgery: 0%). Thus the use rate of arterial grafts were 86.2% in emergency cases (elective surgery: 100%), the patency of the arterial grafts were 100%. It is important to make stable condition of the patients before the operation, and therefore it is important to make contact closely with the cardiologists for making stable condition and for lowering the operative mortality. And, we should use arterial grafts for the long term result as much as possible if it is an urgent operation.

[New screening method for coagulation abnormality including AT III deficiency during CABG]

In our institute, 1 ml of heparin is administered to the patients undergoing CABG before dissection and mobilization of the internal thoracic arteries (ITAs) and/or right gastroepiploic artery (GEA) to prevent possible thrombosis or coagulation tendency. Two patients with AT III deficiency underwent CABG and one of them died. The aim of this study is to know whether ACT check before and after administration of 1 ml of heparin is useful as a screening test of coagulation abnormalities including AT III deficiency. One hundred patients (84 males and 16 females) undergoing CABG were studied. Age ranged from 41 to 79 years (mean 64.8 +/- 8.0 years). One ml of heparin was administered to all the patients before ITAs and/or GEA were dissected and mobilized. ACT was doubly checked before (control ACT: c-ACT) and after (heparinized ACT: h-ACT) administration of heparin. ACT extension was defined as follows: ACT extension = (c-ACT)-(h-ACT). Mean c-ACT was 124 +/- 12 sec., h-ACT 188 +/- 26 sec. and ACT extension 64 +/- 24 sec. There were only 3 cases which ACT extension were less than 30 sec.: two of them were combined with AT III deficiency and the other was due to insufficient administration of heparin. In conclusion, examination of ACT after 1 ml administration of heparin is new, simple and convenient screening method for coagulation abnormalities including AT III deficiency during CABG.

Identification of cDNA encoding cytochrome c oxidase subunit 5c (COX5c) from rice: comparison of its expression with nuclear-encoded and mitochondrial-encoded COX genes

Little is presently known about the nuclear-encoded genes for cytochrome c oxidase (COX) in higher plants. In rice, only the nuclear-encoded COX5b gene has been reported. To understand the relationship between the expression of nuclear-encoded and mitochondrial-encoded COX genes in rice, we first characterized a cDNA encoding one of the other nuclear COX genes, COX5c, which encodes 63 amino acids. The deduced amino acid sequence of COX5c from rice was highly homologous to that from sweet potato. Genomic Southern hybridization indicated that the rice COX5c subunit is encoded by a single copy of the COX5c gene. Furthermore, we compared the expression patterns of the nuclear-encoded COX5c and COX5b genes with the expression pattern of the mitochondrial-encoded COX1 gene among several organs by Northern blot analysis. The results suggested that regulatory systems of expression between the nuclear-encoded and the mitochondrial-encoded COX genes are different among different organs in rice.

Crystal structure determinations of oxidized and reduced plastocyanin from the cyanobacterium Synechococcus sp. PCC 7942

The crystal structures of oxidized and reduced plastocyanins from Synechococcus sp. PCC 7942 have been determined at 1.9 and 1.8 A resolution, respectively, at pH 5.0. The protein consists of only 91 amino acid residues, the smallest number known for a plastocyanin, and apparently lacks the mostly conserved acidic patch that is believed to be important for recognition with electron-transfer partners. The protein has two acidic residues, Glu42 and Glu85, around Tyr83, which is thought to be a possible conduit for electrons, but these are neutralized by Arg88 and Lys58. Residue Arg88 interacts with Tyr83 through a pi-pi interaction in which the guanidinium group of the former completely overlaps the aromatic ring of the tyrosine. Reduction of the protein at pH 5.0 causes a lengthening of one Cu-N(His) bond by 0.36 A, despite the small rms deviation of 0.08 A calculated for the backbone atoms. Moreover, significant conformational changes of Arg88 and Lys58, along with the movement of a water molecule adjacent to the OH group of Tyr83, were observed on reduction; the guanidinium group of Arg88 rotates by more than 11 degrees, and the water molecule moves by 0.42 A. The changes around the copper site and the alterations around Tyr83 may be linked to the reduction of the copper.

Crystallization and preliminary X-ray analysis of plastocyanin from cyanobacterium Synechococcus sp. PCC 7942

A plastocyanin from the cyanobacterium Synechococcus sp. PCC 7942 has been crystallized in two different forms by hanging-drop vapour diffusion with ammonium sulfate as precipitant. Form I is hexagonal, space group P61 or P65, with unit-cell dimensions a = b = 34.62 and c = 107.22 A. Form II is tetragonal, space group P41 or P43, with unit-cell dimensions a = b = 43.05 and c = 56.94 A. Form I crystals diffract to 2.5 A using graphite-monochromated Cu Kalpha radiation from a Rigaku RU-300 rotating-anode generator operated at 40 kV and 100 mA. Form II crystals diffract to 1.9 A using synchrotron radiation at beamline BL6A of the Photon Factory (KEK). Molecular-replacement calculations using the structure of plastocyanin from Ulva pertusa have been performed.

[A case report of intrathoracic aneurysm of left subclavian artery]

A case of intrathoracic aneurysm of the left subclavian artery is reported. The case was 68-year-old male. Chest CT and angiography revealed an aneurysm of left subclavian artery (LSA) located the proximal portion of LSA. The chest was opened by fourth intercostal thoracotomy. We evaluated the intima of distal aortic arch and LSA by introperative direct echography using a small probe (finger tip size). Since there was no calcification or mural thrombi at the distal aortic arch, the aneurysm was resected using partial cardiopulmonary bypass and the orifice of LSA was closed direct suture. LSA was reconstructed with knitted Dacron graft (8 mm). Postoperative course was uneventful.

Galactocerebroside and not glucocerebroside or ceramide stimulate epidermal beta-glucocerebrosidase activity

Glycosphingolipids including glucocerebroside (GluCer) and galactocerebroside (GalCer) have been recognized as bioreguratory lipids by our group and others. In addition, our recent study demonstrated that GalCer corrects dry skin conditions in humans. The processing of stratum corneum lipids, which occurs when beta-glucocerebrosidase (beta-GluCer'ase) changes GluCer to ceramide (Cer), is required to form the epidermal permeability barrier. We herein investigated the effects of GluCer, GalCer and Cer on the processing of GluCer to Cer by assaying epidermal beta-GluCer'ase in mice (155%, P < 0.01) when compared to vehicle treated controls, while neither GluCer nor Cer had this effect. Studies using inhibitors of beta-GluCer'ase or beta-galactosidase and measuring the optimum pH of the enzyme verified that GalCer specifically activated beta-GluCer'ase. We confirmed that GalCer significantly increased beta-GluCer'ase activity in the outer epidermal fraction (172%, P < 0.01) and that the activation of beta-GluCer'ase is not due to a direct activating effect of GalCer on the enzyme. Furthermore, the induction of beta-GluCer'ase activity by GalCer was also observed in cultured normal human deratinocytes (123%, P < 0.01). Finally, acylceramide content in stratum corneum was increased in mice treated with GalCer (194%, P < 0.0005). These results indicate that GalCer appears to affect the Cer construct in the stratum corneum by the activation of beta-GluCer'ase, which ultimately contribute to an enhancement of barrier formation.

[Case report of successful treatment of patent ductus arteriosus with severe pulmonary hypertension in an adult]

A 40-year-old man was diagnosed as having PDA with severe PH by cardiac catheterization. We decided that surgery was indicated on the basis of 100% oxygen inhalation test. After 100% oxygen inhalation, left to right shunt changed from 37.8% to 61.5%, Qp/Qs changed from 1.43 to 2.60, and PVR changed from 1,199 dyne/sec/cm5 to 237 dyne/sec/cm5. We decided to perform surgery. Under extracorporeal circulation, PDA was safely closed by triple ligation and was directly closed after pulmonary arteriotomy. The postoperative course was uneventful. Severe PH was greatly improved, pulmonary artery pressure recovering to the normal range, by administering PGE1, prostacyclin (PGI2), and nitroglycerin.

[A case of an adult patient of tetralogy of Fallot having malignant hyperthermia during surgery]

An episode of malignant hyperthermia occurring in a 42-year-old man undergoing hypothermic cardiopulmonary bypass is reported. Malignant hyperthermia is a syndrome initiated by a hypermetabolic state of skeletal muscle. A patient presented for correction of an acyanotic tetralogy of Fallot. The coincidental usage of hypothermic cardiopulmonary bypass obscured the classical presenting sings and symptoms of the malignant hyperthermia. And the disease of tetralogy of Fallot made the syndrome difficult to manage. Although the clinical diagnosis of malignant hyperthermia is difficult to be confirmed, when it is suspected, it is prudent for the case to be initially treated as malignant hyperthermia.

[Coronary artery bypass surgery in patients aged 75 years and older]

Coronary artery bypass grafting (CABG) has been performed for elderly patients with increasing frequency. Several studies have shown that the rate of complications and mortality in elderly patients are higher than in younger ones. This report presents results of CABG in patients over 75 years old. From January 1989 to February 1997, 604 patients underwent CABG, of whom 20 patients (3.3%) were 80-86 years old (group A) and 57 patients (9.4%) were 75-79 years old (group B). We compared these two groups with 100 younger patients (group C). Preoperative use of intraaortic balloon pumping and the emergency operation were more frequent in patients of group A (emergency 45%, IABP 20%). And the proportion of the no blood transfusion procedures was lower in elderly patients (group A 20%, group B 18%, group C 82%). The number of grafts per patient (group A 2.45 +/- 0.62, group B 2.2 +/- 0.6, group C 3.2 +/- 0.6) and the number of arterial grafts (group A 1.25 +/- 0.62, group B 1.25 +/- 0.66, group C 2.1 +/- 0.53) were different between the groups. But CABG in elderly patients was performed with low hospital mortality (group A 0%, group B 0.18%) and significant symptomatic benefit. We conclude that CABG can be performed in elderly patients with acceptable mortality and acceptable quality of life, so patients should not denied operation because of an advanced age.

[A surgical case of total anterior papillary muscle rupture after acute myocardial infarction]

Mitral regurgitation (MR) due to rupture of the papillary muscle is one of the most serious complications of acute myocardial infarction (AMI) as well as ventricular septal perforation and ventricular free wall rupture. We experienced a case of complete rupture of the anterior papillary muscle. A 68-year-old man experienced an episode of dyspnea. Electrocardiographic findings were consistent with postero-lateral infarction. Massive MR is present on color Doppler imaging. He was transferred to our hospital for urgent operative indication because of papillary muscle rupture due to AMI. Six hours after the onset, the operation was performed with intra-aortic balloon pump in place. The anterior papillary muscle was ruptured completely in the mid portion. He underwent a mitral valve replacement with a SJM prosthetic valve. There is a few cases with successful urgent surgery for a complete rupture of anterior papillary muscle.

A case of recessive X-linked ichthyosis: scale-specific abnormalities of lipid composition may explain the pathogenesis of the skin manifestation

We analyzed the lipid content of the scales, red blood cells, and plasma from a recessive X-linked icthyosis patient. The patient's scales accumulated cholesterol sulfate, had decreased levels of free sterols, sterol esters and sphingolipids, and lacked phospholipids. Although the accumulation of cholesterol sulfate was found in the patient's red blood cells and plasma as well as in the scales, other lipid composition abnormalities were specific for scales. Such scale-specific abnormal lipid composition may explain the pathogenesis of generalized hyperkeratosis and abnormal scaling of the disease.

Leiomyoblastoma and leiomyomatosis of the small intestine in a case of von Recklinghausen's disease

A 70-year-old patient with von Recklinghausen's neurofibromatosis 1 (NF1) developed a stomach ulcer and underwent a total gasterectomy. During the laparotomy, a leiomyoblastoma and multiple leiomyomas, which were histologically diagnosed as such later, were found in the small intestine and resected. It is quite possible that the association of gastrointestinal leiomyomas and NF1 is more than coincidental. It is thus important to take this complication into account in clinical treatment of patients with NF1.

Sialyl Lewis(a) ganglioside in pancreatic cancer tissue correlates with the serum CA 19-9 level

CA 19-9 ganglioside antigen was extracted from the tumors of 16 patients with pancreatic cancer and the antigen was confirmed by mass spectrometry to be a sialyl Lewis(a) ganglioside. Ductal adenocarcinomas from four patients, two whose Lewis blood phenotype was Le(a- b-), one with undifferentiated carcinoma, and one with an acinar cell carcinoma, did not contain detectable amounts of sialyl Le(a) ganglioside. A significant correlation was found between serum CA 19-9 levels and the recovery of ganglioside antigen from respective tumors, but not tumor burden.

[Surgical treatment of infective endocarditis : an analysis of the risk factor for operative mortality]

From January 1980, through December 1995, 60 patients underwent surgical treatment of infective endocarditis (IE) at Sakakibara Hospital. Of 60 patients, 40 showed active endocarditis and 20 healed endocarditis at the time of operation. The over-all hospital mortality was 10% (6/60). The complication of cerebral accident (embolism and bleeding) was related to a higher incidence of operative mortality. The reconstructions of destruction and disruption of ventricular-aortic or mitral-aortic continity in the presence of acute infection of the annular tissue were in need of radical and complex surgical techniques. It is recommended to follow up these patients thoughtfully and to perform reoperation or re-reoperation before a patient develops severe heart failure or multiple organ failure.

Multiple malignant eccrine poroma and a linear epidermal nevus

A 68-year-old woman developed three reddish nodules on a linear epidermal nevus on the right arm. The nodules and linear lesion were resected. The histology revealed the two larger nodules to be eccrine porocarcinoma and the other to be eccrine poroepithelioma. The linear lesion was actually epidermal nevus. To our knowledge, this is the first description of adnexal tumors developing on epidermal nevus.

Effect of a chemically-synthesized acylglucosylceramide, epidermoside, on normal human keratinocyte differentiation

Epidemosides (N-(0-linoleoyl)-(1)-hydroxy fatty acyl sphingosyl glucose) are found exclusively in the epidermis not in dermis, and are thought to play important role in forming the mammalian epidermal permeability barrier. A species of epidermoside isolated from guinea pig epidermis and named lipokeratinogenoside has been shown to enhance fetal rat keratinocyte differentiation. In the present investigation, we studied the effects of a chemically synthesized equivalent of human epidermoside on the viability and differentiation of cultured human keratinocytes (HK Cells). The chemically-synthesized epidermoside was not toxic to cultured HK Cells at concentrations of 0.01 to 10 micrograms/ml. When 10 micrograms/ml of the chemically-synthesized epidermoside was added to keratinocyte growth medium containing 1.2 mM Ca2+, HK Cells showed a 5.6-fold increase of keratin content compared to the vehicle treated control at 144 h of cultivation, and they also displayed morphological changes suggestive of differentiation. A similar increase of cellular keratin content was observed in HK cells treated with tetradecanoyl phorbol-13 myristyl-12 acetate (TPA), an agent known to enhance the differentiation of keratinocytes. Lipokeratinogenoside also increased the keratin content of cultured HK cells. These results suggest that epidermosides have an ability to enhance keratinocyte differentiation. Epidermoside could thus be a key molecule, not only as a constituent of the epidermal permeability barrier, but also as a regulator of keratinocyte differentiation.

Tumor necrosis factor-alpha stimulates the production of squamous cell carcinoma antigen in normal squamous cells

Squamous cell carcinoma (SCC) antigen, a tumor marker of squamous cell carcinoma, is also increased in several nonmalignant skin lesions, e.g. pemphigus. The aim of the present investigation was to determine if tumor necrosis factor-alpha (TNF-alpha), one of the important environmental factors, stimulated the production of SCC antigen in the normal squamous cells. The exposure of normal human epidermal keratinocytes to TNF-alpha (100 IU/ml) for 72 h greatly increased the SCC antigen production. The stimulatory effect of TNF-alpha (1,000 IU/ml) on the production of SCC antigen was also observed in the normal squamous epithelium tissue. These results would be helpful for understanding the increase of SCC antigen in several nonmalignant skin disorders.

Immunohistological reaction mechanism of anti-monosialoganglioside monoclonal antibody, MAb 202, showing predominant cytotoxicity for malignant melanoma

Mouse monoclonal IgM antibody (MAb 202) can cause melanoma cell necrosis in vivo. We analysed its immune mechanism in three melanoma patients to whom MAb 202 was administered. After the MAb 202 administration, histopathological analysis showed necrosis of melanoma cells expressing only GM3 in two patients. Another patient carrying both GM3 and GD3 showed infiltration of lymphocytes within the tumor nest but no tumor cells or nest necrosis. Immunohistological examination using anti-mouse IgM antibody revealed MAb 202 bound on the surface of melanoma cells in two patients but not in the third (positive for both GM3 and GD3). In vitro, MAb 202 reacted with the melanoma cells of the same two patients, but not with any other tissues of these individuals. We found no reaction of MAb 202 to non-melanoma cells including normal melanocytes and glia cells. Our trials suggest, 1) MAb 202 reacts directly to monosialogangliosides on the melanoma cell surface and then leads to the cytotoxicity reaction, or 2) MAb 202 induces lymphocyte infiltration and possibly then promotes the secretion of some cytokines.

Glycosphingolipids in human pancreatic juice. Unique fatty acid compositions of glucosylceramides and lactosylceramides

Glycosphingolipids in human pancreatic juice were isolated and purified by DEAE and silica gel column chromatographs, and further by HPLC on silica gel and reversed-phase columns. The structures of the glycosphingolipids were determined to be glycosylceramides and lactosylceramides by means of fast atom bombardment mass spectrometry, 1H-NMR spectroscopy, and component analysis involving GLC-mass spectrometry. The ceramide portions of the glucosylceramides consist of palmitic, tetracosanoic, and alpha-hydroxy tetracosanoic fatty acids, and d18:1 and t18:0 sphingosines. The ceramide portions of the lactosylceramides consist of palmitic, teracosanoic, tetracosenoic, and tetracosadienoic fatty acids, and d18:1 sphingosine. The fatty acid compositions are different from the free fatty acid compositions of serum and pancreatic juice. The predominance of saturated, unsaturated, and hydroxy tetracosanoic fatty acid is quite unique, and the possibility that these glycosphingolipids may play a specific role in pancreatic juice deserves consideration. These glycosphingolipids were documented to be major components of the pancreatic juice from 15 patients with a variety of pancreatic diseases.

A case of multiple eccrine porocarcinoma with stepping-stone distribution on the foot

An 89-year-old woman had three tumors of several years' duration in a stepping-stone distribution on the dorsum of her right foot. The two larger ones were diagnosed histologically as eccrine porocarcinomas, and the smallest of the three shared many clinical similarities with them. Eccrine porocarcinoma is a rare malignant tumor. We describe this peculiar case in which three tumors developed in the same region and discuss how they might have occurred. It is most likely that the three tumors of this case originated from nevoid tumors, and that the individual lesions exhibited malignant changes.

Lipid composition and fatty acid analysis of Helicobacter pylori

Lipids extracted from Helicobacter pylori were separated into lipid classes by thin-layer chromatography. Simple H. pylori lipids consisted of cholesterol esters, triglycerides, free fatty acids, cholesterol, diacylglycerols, and monoacylglycerols. Fatty acids were released from each lipid class by acid methanolysis, and analyzed by gas liquid chromatography and mass spectrometry. Unique methoxy fatty acids, including 11-methoxy heptadecanoic and 11-methoxy nonadecanoic acids, were the major components of the cholesterol esters and triglycerides. The predominance of methoxy fatty acids in the cholesterol esters of H. pylori may contribute to the acid-resistant characteristic of this bacillus.

Polysialogangliosides expressed by amelanotic melanoma: a possible explanation for the poor response to anti-monosialoganglioside antibody 202 in a patient with melanoma

A 52-year-old Japanese woman developed numerous amelanotic metastatic melanomas on the skin and in various organs three years after a surgical operation for primary melanoma on the right axilla. The patient was treated with monosialoganglioside specific monoclonal antibody 202; however, no apparent clinical effects were observed. Ganglioside analysis of a metastatic tumor demonstrated that it expressed GM3, GM2, GD3, GD2, and polysialogangliosides. Since polysialogangliosides rarely appear in melanomas, their expression may explain the patient's poor response to MAb 202. The relationship between ganglioside composition and the effect of anti-ganglioside monoclonal antibody is discussed.

Expression of sialylparagloboside in a case of liposarcoma: aberrant glycosylation in tumors arising in adipose tissues

Gangliosides of liposarcoma, lipoma and lipids from omental tissues were analyzed. By immunostaining after thin layer chromatography, gangliosides of liposarcoma were identified as GM3, sialylparagloboside and GD3, whereas those of lipoma were GM3 and GD3, and those of fat in omental tissues were GM3, GD1a, GD3 and some unknown ones. Expression of sialylparagloboside is thought to be very rare.

Tissue accumulation of sulfatide and GM3 ganglioside in a patient with variant Farber disease

We analyzed the lipids in the tissues of a patient with an atypical form of Farber disease who developed several clinical symptoms not seen in patients with typical Farber disease (acid ceramidase deficiency). Lipids were extracted from formalin-fixed brain, liver and kidney and purified by ion exchange and silica gel column chromatographies and further by high-performance liquid chromatography on a silica gel column. We performed structural and quantitative analyses of three lipids named lipids X, Y and Z. Lipid X accumulated in the liver but not in the brain. Accumulation of lipids Y and Z was observed in liver and kidney. The content of lipid Y in the patients liver was more than ten times that in a control. The structures of lipids X, Y and Z were confirmed by means of 1H-nuclear magnetic resonance spectroscopy, fast atom bombardment mass spectrometry, infrared absorption spectroscopy, and component analysis involving gas liquid chromatography and gas chromatography-mass spectrometry. The structures of lipids X, Y and Z were identified as those of ceramide, sulfatide and GM3 ganglioside, respectively. These results suggest two possibilities. One is that the accumulation of glycolipids such as sulfatide and GM3 ganglioside is a secondary event produced by the accumulation of ceramide due to ceramidase deficiency. The other is that the accumulation of glycolipids other than ceramide is due to a deficiency of sphingolipid activator proteins which may affect the degradation of sulfatide and GM3 ganglioside as well as ceramide.