A Photoactivated Protein Degrader for Optical Control of Synaptic Function

Hundreds of proteins determine the function of synapses, and synapses define the neuronal circuits that subserve myriad brain, cognitive, and behavioral functions. It is thus necessary to precisely manipulate specific proteins at specific sub-cellular locations and times to elucidate the roles of particular proteins and synapses in brain function. We developed PHOtochemically TArgeting Chimeras (PHOTACs) as a strategy to optically degrade specific proteins with high spatial and temporal precision. PHOTACs are small molecules that, upon wavelength-selective illumination, catalyze ubiquitylation and degradation of target proteins through endogenous proteasomes. Here we describe the design and chemical properties of a PHOTAC that targets Ca 2+ /calmodulin-dependent protein kinase II alpha (CaMKIIα), which is abundant and crucial for baseline synaptic function of excitatory neurons. We validate the PHOTAC strategy, showing that the CaMKIIα-PHOTAC is effective in mouse brain tissue. Light activation of CaMKIIα-PHOTAC removed CaMKIIα from regions of the mouse hippocampus only within 25 μm of the illuminated brain surface. The optically-controlled degradation decreases synaptic function within minutes of light activation, measured by the light-initiated attenuation of evoked field excitatory postsynaptic potential (fEPSP) responses to physiological stimulation. The PHOTACs methodology should be broadly applicable to other key proteins implicated in synaptic function, especially for evaluating their precise roles in the maintenance of long-term potentiation and memory within subcellular dendritic domains.

Aberrant interaction between TEAD1 and Lamin A/C causes cardiomyopathy

Background

Mutations in the LMNA gene encoding Lamin A/C, a major component of the nuclear lamina, cause laminopathies including dilated cardiomyopathy (DCM). DCM patients with LMNA mutations have particularly severe clinical courses such as heart transplantation and death due to heart failure. However, underlying mechanisms of LMNA-induced DCM remains elusive.

Methods and results

We identified LMNA Q353R mutation in a DCM family with severe heart failure. We generated Q353R heterozygous knock-in mice, which showed sarcomere dysplasia and perinatal lethality. Integrative single-cell analyses of the fetal murine hearts and patient-specific induced pluripotent stem cell-derived cardiomyocytes (iPSCMs) revealed that transcriptional regulation of cardiomyocyte maturation/development genes governed by TEAD1 was impaired in LMNA mutant cardiomyocytes. Protein array and immunostaining uncovered increased binding of TEAD1 to mutant Lamin A/C protein and abnormal localization of TEAD1 at the nuclear periphery. Furthermore, TT-10, a Hippo pathway inhibitor, rescued the dysregulation of cardiac developmental genes in LMNA mutant cardiomyocytes. Single-cell RNA-seq of cardiac tissues from DCM patients with the LMNA Q353R mutation confirmed the dysregulated expression of TEAD1 and its target genes. These results demonstrated abnormal interaction between TEAD1 and mutant Lamin A/C impairs structural maturation of cardiomyocytes and suggests that LMNA Q353R-related DCM can be treated through intervention in the Hippo pathway.

Conclusion

TEAD1 trapped by mutant Lamin A/C protein at the nuclear membrane perturbs transcriptional maturation in LMNA Q353R-related DCM.

Funding Acknowledgement

Type of funding sources: None.

P-233 Deep ensembles-based AI as a tool to support embryo grading and clinical pregnancy prediction

Study question

Can deep learning accurately evaluate embryo grades and predict clinical pregnancy while providing relevant clinical evidence, not just results from a black box?

Summary answer

The sophisticated ensemble method can improve the predictive performance for embryo grades and clinical pregnancy, while providing clinically relevant evidence.

What is known already

Previous studies have shown that AI can predict the IVF outcomes by analyzing the images of embryos. In many literature, AI outperformed human because AI could identify features human eyes could not easily detect. However, clinicians have been cautious to adopt the AI technology due to the black box nature of AI algorithms. In this study, we increased the predictive power of AI as well as providing evidence of the prediction by using deep ensembles and Grad-CAM images.

Study design, size, duration

We performed a retrospective study of single static images of 727 Day 5 blastocysts from 270 patients who underwent single embryo transfer at a single in vitro fertilization (IVF) clinic between January 2015 and March 2021. The images were collected from standard optical light microscopes and matched with metadata such as embryo grades and pregnancy outcomes.

Participants/materials, setting, methods

Two different models were designed: an automatic embryo grading model and a pregnancy prediction model. Embryologists labeled a day 5 embryo “GEM,” a good embryo if 4AA/AB or above in the Gardner system and pregnancy was defined as the presence of a fetal heartbeat (FHB). Deep ensembles were applied by training four convolutional neural networks (CNNs) and Grad-CAM images were extracted from the last layer and reviewed by experts.

Main results and the role of chance

Under several single CNNs, the highest AUROCs of the embryo grading model and the pregnancy prediction model were 0.80 and 0.67, respectively. After applying deep ensembles, the AUROCs of the two models increased to 0.84 and 0.72, respectively. When the F1-score for the positive cases were maximized by adjusting the threshold of ensembles, accuracy, sensitivity and specificity of the embryo grading model were 88.1%, 92.9% and 62.5% respectively. For the pregnancy prediction model, accuracy, sensitivity and specificity were 66.3%, 77.1% and 55.6% respectively. The accuracy of GEM predicting pregnancy for the embryologists and the embryo grading AI model was 47.3% and 59.2%, respectively. It is noteworthy that the AI pregnancy prediction model outperformed the embryologists while successfully auto-grading embryos, a strong evidence that AI considered more features for prediction than what was used for grading. It was also noted from the review of the Grad-CAM images that the both AI models were focusing on the ICM, TE and hatching. Although their area of focus was the same, the pregnancy prediction model was able to make better predictions than the embryologists and the embryo grading model.

Limitations, reasons for caution

This study has limitations as it is a retrospective study performed on embryo images from a single IVF center. In addition, including other variables such as clinical data may enhance the models.

Wider implications of the findings

We showed that deep learning can automatically grade embryos and more accurately predict pregnancy than embryologists. Furthermore, the embryologists confirmed the model was looking at key features like ICM, TE and hatching. Sharing such evidence with clinicians can be a necessary step for AI to be adopted for clinical practice.

Trial registration number

not applicable

Performance of a targeted cell-free DNA prenatal test for 22q11.2 deletion in a large clinical cohort

OBJECTIVE

22q11.2 deletion is more common than trisomies 18 and 13 combined, yet no routine approach to prenatal screening for this microdeletion has been established. This study evaluated the clinical sensitivity and specificity of a targeted cell-free DNA (cfDNA) test to screen for fetal 22q11.2 deletion in a large cohort, using blinded analysis of prospectively enrolled pregnancies and stored clinical samples.

METHODS

In order to ensure that the analysis included a meaningful number of cases with fetal 22q11.2 deletion, maternal plasma samples were obtained by prospective, multicenter enrolment of pregnancies with a fetal cardiac abnormality and from stored clinical samples from a research sample bank. Fetal genetic status, as evaluated by microarray analysis, karyotyping with fluorescence in-situ hybridization or a comparable test, was available for all cases. Samples were processed as described previously for the Harmony prenatal test, with the addition of DANSR (Digital Analysis of Selected Regions) assays targeting the 3.0-Mb region of 22q11.2 associated with 22q11.2 deletion syndrome. Operators were blinded to fetal genetic status. Sensitivity and specificity of the cfDNA test for 22q11.2 deletion were calculated based on concordance between the cfDNA result and fetal genotype.

RESULTS

The final study group consisted of 735 clinical samples, including 358 from prospectively enrolled pregnancies and 377 stored clinical samples. Of 46 maternal plasma samples from pregnancies with a 22q11.2 deletion, ranging in size from 1.25 to 3.25 Mb, 32 had a cfDNA result indicating a high probability of 22q11.2 deletion (sensitivity, 69.6% (95% CI, 55.2-80.9%)). All 689 maternal plasma samples without a 22q11.2 deletion were classified correctly by the cfDNA test as having no evidence of a 22q11.2 deletion (specificity, 100% (95% CI, 99.5-100%)).

CONCLUSIONS

The results of this large-scale prospective clinical evaluation of the sensitivity and specificity of a targeted cfDNA test for fetal 22q11.2 deletion demonstrate that this test can detect the common and smaller, nested 22q11.2 deletions with a low (0-0.5%) false-positive rate. Although the positive predictive value (PPV) observed in this study population was 100%, the expected PPV in the general pregnant population is estimated to be 12.2% at 99.5% specificity and 41.1% at 99.9% specificity. The use of this cfDNA test to screen for 22q11.2 deletion could enhance identification of pregnancies at risk for 22q11.2 deletion syndrome without significantly increasing the likelihood of maternal anxiety and unnecessary invasive procedures related to a false-positive result. © 2021 The Authors. Ultrasound in Obstetrics & Gynecology published by John Wiley & Sons Ltd on behalf of International Society of Ultrasound in Obstetrics and Gynecology.

Stratifying the prognostic capability of cardiovascular magnetic resonance in severe aortic stenosis: a machine learning approach

Background

Cardiovascular magnetic resonance (CMR) demonstrates promise in improving patient risk stratification in aortic stenosis (AS). We explored whether machine learning might provide further insights into the prognostic capability of CMR parameters.

Methods

Severe AS patients (n=440) undergoing AVR were prospectively enrolled across 10 international sites, and CMR performed prior to AVR. A machine learning prediction model using a random survival forest (RSF) was trained with 29 variables, including 13 CMR, 4 echocardiography, and 12 clinical parameters, using post-AVR mortality as an outcome. The impact of the important variables on the outcome (partial dependency) was examined.

Results

The most predictive CMR parameters in the RSF model were the extracellular volume fraction (ECV%), followed by right ventricular ejection fraction (RVEF), late gadolinium enhancement (LGE%), and indexed left ventricular end-diastolic volume (LVEDVi). Regarding the partial effects, the predicted mortality increased strongly once the ECV% exceeded 26.5% (Figure 1A). The LGE% was associated with an increased risk of mortality, which reached a plateau beyond the level of 2% (Figure 1C). There were U-shaped relationships between mortality and both RVEF and LVEDVi, with the lowest mortality seen at RVEF 70% and LVEDVi 68ml/m2 (Figure 1B, D). These trends of predicted outcomes by each variable were verified in the Kaplan-Meier curves and Cox analyses (Table). In both Cox and RSF models, the predictability was substantially increased when these four CMR parameters were added to conventional clinical risk factors. An AS-CMR risk score comprised of these four parameters presented a stepwise increase in mortality with increasing adverse CMR features (p<0.001).

Conclusions

Our machine learning analysis using RSF has identified ECV%, RVEF, LGE%, and LVEDVi as key prognostic markers in severe AS with a nonlinear influence of each parameter on mortality post-AVR.

Figure 1

Funding Acknowledgement

Type of funding source: Public grant(s) – National budget only. Main funding source(s): This study was supported by grants from the Korean Health Technology R & D Project, Ministry of Health, Welfare & Family Affairs, Republic of Korea (HI16C0225 and HI15C0399) and the National Institute for Health Research (NIHR) infrastructure at Leeds.

Discordance of patient and physician health status concerns in systemic lupus erythematosus

Objectives To compare the health status concerns of patients with systemic lupus erythematosus (SLE) and of their physicians. Methods Cross-sectional questionnaire study of SLE patients and their treating physicians at a tertiary disease-specific outpatient clinic. Patients and physicians completed a questionnaire regarding their concern about specific disease manifestations and impact on quality of life. For each item, degree of concern was rated on a five-point Likert scale and summarized as median (interquartile range). Ratings between patients and physicians were compared using Mann-Whitney U tests. Results A total of 84 patients and 21 physicians participated. Patients' predominant concerns centred on function and fatigue, whereas physicians' concerns focused on SLE-related organ complications. Of the 10 highest ranked patient concerns, only two were common to the 10 highest ranked physician concerns, while physicians rated seven significantly differently; all 10 highest ranked physician concerns were rated significantly lower by patients. The three highest ranked patient concerns (fatigue, pain and feeling worn out) were routinely assessed by 47.6%, 42.9% and 9.5% of physicians, respectively. Conclusion There was significant discordance between SLE patient and physician health status concerns. Items which were ranked highly by patients were not assessed consistently by physicians, highlighting a significant gap in healthcare communication.

Validation of the Lupus Impact Tracker in an Australian patient cohort

OBJECTIVES

The objective of this article is to validate the Lupus Impact Tracker (LIT), a disease-specific patient-reported outcome (PRO) tool, in systemic lupus erythematosus (SLE) patients in a multi-ethnic Australian cohort.

METHODS

Patients attending the Monash Lupus Clinic were asked to complete the LIT, a 10-item PRO. Psychometric testing assessing criterion validity, construct validity, test-retest reliability (TRT) and internal consistency reliability (ICR) were performed. We compared the LIT scores across patient characteristics, and correlations between LIT scores and SLEDAI-2k, PGA, and SLICC-SDI were examined.

RESULTS

LIT data were obtained from 73 patients. Patients were 84% female with a median age of 41 years, and 34% were Asian. The cohort had mild-moderate disease activity with a median (IQR) Systemic Lupus Erythematosus Disease Activity Index-2000 (SLEDAI-2k) of 4 (IQR 2-6). The median LIT score was 32.5 (IQR 17.5-50). LIT demonstrated criterion validity against SLEDAI-2k and SDI. Construct validity assessed by confirmatory factor analysis demonstrated an excellent fit (Goodness of fit index 0.95, Comparative Fit Index 1, Root Mean Square Error of Approximation <0.0001). The LIT demonstrated TRT with an overall intraclass correlation coefficient of 0.986 (95% CI 0.968-0.995). ICR was demonstrated with a Cronbach's alpha of 0.838. Patients with disability, low socioeconomic status, or higher disease activity had significantly worse LIT scores.

CONCLUSION

The LIT demonstrated properties consistent with its being valid in this population. Lower socioeconomic status appears to have a significant impact on patient-reported health-related quality of life in SLE.

Inhibition of prostasin-induced ENaC activities by PN-1 and regulation of PN-1 expression by TGF-beta1 and aldosterone

Prostasin has been shown to regulate sodium handling in the kidney. Recently, a serine protease inhibitor, protease nexin-1 (PN-1), was identified as an endogenous inhibitor for prostasin. Therefore, we hypothesized that PN-1 may regulate sodium reabsorption by reducing prostasin activity, and that expression of PN-1 was regulated by transforming growth factor-beta1 (TGF-beta1) or aldosterone, like prostasin. cRNAs for epithelial sodium channel (ENaC), prostasin, and PN-1 were expressed in Xenopus oocytes, and the amiloride-sensitive sodium currents (I(Na)) were measured. The effect of TGF-beta1 and aldosterone on the mRNA and protein abundance of PN-1 and ENaC was detected by real-time polymerase chain reaction and immunoblotting in M-1 cells. Expression of PN-1 substantially decreased prostasin-induced I(Na) by approximately 68% in oocytes. Treatment of M-1 cells with 20 ng/ml TGF-beta1 significantly increased protein expression of PN-1 by 3.8+/-0.5-fold, whereas administration of 10(-6) M aldosterone markedly decreased protein expression of PN-1 to 53.7+/-6.7%. Basolateral, but not apical, application of TGF-beta1 significantly reduced I(eq). To elucidate the involvement of PN-1 in basal ENaC activity, we silenced the expression of PN-1 by using short-interfering RNA. This increased I(eq) by 1.6+/-0.1-fold. Our study indicates that PN-1 could have a natriuretic role by inhibiting prostasin activity and suggests the possibility that aldosterone and TGF-beta reciprocally regulate the expression of PN-1 in renal epithelial cells contributing to salt retention or natriuresis, respectively by an additional mechanism. PN-1 could represent a new factor that contributes to regulation of ENaC activity in the kidney.

Ultrahigh resolution real time OCT imaging using a compact femtosecond Nd:Glass laser and nonlinear fiber

Ultrahigh resolution, real time OCT imaging is demonstrated using a compact femtosecond Nd:Glass laser that is spectrally broadened in a high numerical aperture single mode fiber. A reflective grating phase delay scanner enables broad bandwidth, high-speed group delay scanning. We demonstrate in vivo, ultrahigh resolution, real time OCT imaging at 1 microm center wavelength with <5 microm axial resolution in free space (<4 microm in tissue). The light source is robust, portable, and well suited for in vivo imaging studies.

The first episode of psychosis: the experience of relatives

OBJECTIVE

The aim was to determine the extent of and the correlates of the distress and impact of care families of patients with first episode psychosis were experiencing when they first came for treatment.

METHOD

Subjects were 238 individuals who had presented with a first episode of psychosis and their family members. Family members were assessed with the Psychological General Well-Being Scale, and the Experience of Caregiving Inventory. Patient data included assessment of positive and negative symptoms, depression, quality of life, and substance use.

RESULTS

Family members of these first-episode patients were experiencing distress and difficulties. It was the family's appraisal of the impact of the illness that was associated with their psychological well-being.

CONCLUSION

As the majority of these first episode families are keen to be involved early and have engaged in an intervention programme, the next step should be an evaluation of their involvement to determine if it is effective.

The effects of polishing and bleaching on the colour of discoloured teeth in vivo

Bleaching is an effective method for restoring the colour of discoloured vital teeth. Power bleaching, in particular, in which a bleaching solution containing 35% hydrogen peroxide is activated by a strong light source using a plasma arc, makes it possible to bleach teeth effectively in a short time. The purpose of this study was to determine how polishing or power bleaching the tooth surface affects tooth colour. The subjects selected were patients who had slightly discoloured teeth. The colour of precisely identified sites on six anterior teeth was measured before treatment, after polishing and after bleaching, to ascertain changes in colour. The measurements revealed that tooth colour changes slightly after polishing, but it shows a much greater change after bleaching, and that the post-bleaching change in tooth colour was caused both by elevation of lightness and reduction of yellowness. They also revealed that the colour difference between pre-treatment and post-bleaching does not depend on the type of tooth. These results suggested that power bleaching is an effective technique for improving slightly discoloured vital teeth, regardless of the type of tooth.

Promotion of breastfeeding intervention trial (PROBIT): a cluster-randomized trial in the Republic of Belarus. Design, follow-up, and data validation

This paper summarizes the objectives, design, follow-up, and data validation of a cluster-randomized trial of a breastfeeding promotion intervention modeled on the WHO/UNICEF Baby-Friendly Hospital Initiative (BFHI). Thirty-four hospitals and their affiliated polyclinics in the Republic of Belarus were randomized to receive BFHI training of medical, midwifery, and nursing staffs (experimental group) or to continue their routine practices (control group). All breastfeeding mother-infant dyads were considered eligible for inclusion in the study if the infant was singleton, born at > or = 37 weeks gestation, weighed > or = 2500 grams at birth, and had a 5-minute Apgar score > or = 5, and neither mother nor infant had a medical condition for which breastfeeding was contraindicated. One experimental and one control site refused to accept their randomized allocation and dropped out of the trial. A total of 17,795 mothers were recruited at the 32 remaining sites, and their infants were followed up at 1, 2, 3, 6, 9, and 12 months of age. To our knowledge, this is the largest randomized trial ever undertaken in area of human milk and lactation. Monitoring visits of all experimental and control maternity hospitals and polyclinics were undertaken prior to recruitment and twice more during recruitment and follow-up to ensure compliance with the randomized allocation. Major study outcomes include the occurrence of > or = 1 episode of gastrointestinal infection, > or = 2 respiratory infections, and the duration of breastfeeding, and are analyzed according to randomized allocation ("intention to treat"). One of the 32 remaining study sites was dropped from the trial because of apparently falsified follow-up data, as suggested by an unrealistically low incidence of infection and unrealistically long duration of breastfeeding, and as confirmed by subsequent data audit of polyclinic charts and interviews with mothers of 64 randomly-selected study infants at the site. Smaller random audits at each of the remaining sites showed extremely high concordance between the PROBIT data forms and both the polyclinic charts and maternal interviews, with no evident difference in under- or over-reporting in experimental vs control sites. Of the 17,046 infants recruited from the 31 participating study sites, 16,491 (96.7%) completed the study and only 555 (3.3%) were lost to follow-up. PROBIT's results should help inform decision-making for clinicians, hospitals, industry, and governments concerning the support, protection, and promotion of breastfeeding.

Autocrine TGFbeta signaling mediates vitamin D3 analog-induced growth inhibition in breast cells

In this study, we address whether TGFbeta signaling mediates vitamin D3 analog-induced growth inhibition in nonmalignant and malignant breast cells. Normal mammary epithelial cells (184), immortalized nonmalignant mammary epithelial cells (184A1 and MCF10A), and breast cancer cells (early passage MCF7: MCF7E) were sensitive to the inhibitory effects of vitamin D3 analogs (EB1089 and MC1288) while late passage MCF7 breast cancer (MCF7L) cells were relatively resistant. A similar pattern of sensitivity to TGFbeta was observed with these cells. Thus, the sensitivity to the vitamin D3 analogs correlated with the sensitivity to TGFbeta. MCF7L TGFbetaRII-transfected cells, which have autocrine TGFbeta activity, were more sensitive to EB1089 than MCF7L cells. TGFbeta neutralizing antibody was found to block the inhibitory effects of these analogs. These results are consistent with the idea that autocrine TGFbeta signaling mediates the anti-proliferative effects of the vitamin D3 analogs in these cells. The expression of TGFbeta isoforms and/or TGFbeta receptors was induced by the analogs in the vitamin D3 and TGFbeta sensitive cells. Vitamin D3 analogs did not induce TGFbeta or TGFbeta receptor expression in the resistant MCF7L cells. Therefore, EB1089 induces autocrine TGFbeta activity through increasing expression of TGFbeta isoforms and/or TGFbeta receptors. In addition, EB1089 induced nuclear VDR protein levels in the sensitive 184A1 cells but not in the resistant MCF7L cells. 184A1 cells were more sensitive to EB1089-induced VDR-dependent transactivation than MCF7L cells as measured by a luciferase reporter construct containing the VDRE, indicating a defect of VDR signaling in MCF7L cells. Smad3, a TGFbeta signaling mediator, coactivated VDR-dependent transactivation in 184A1 cells but not in MCF7L cells. These results indicate that Smad3 coactivates VDR to further enhance TGFbeta signaling and vitamin D3 signaling in the sensitive 184A1 cells. The results also indicate that Smad3 is not of itself sufficient to coactivate VDR in TGFbeta/vitamin D3 resistant MCF7L cells and other factors are required. We found that the PI 3-kinase pathway inhibitor LY29004 inhibited the synergy of TGFbeta and EB1089 on VDR-dependent transactivation activity. This indicates that the crosstalk between TGFbeta and vitamin D signaling is also PI 3-kinase pathway dependent.

Imaging needle for optical coherence tomography

We describe a miniature optical coherence tomography (OCT) imaging needle that can be inserted into solid tissues and organs to permit interstitial imaging of their internal microstructures with micrometer scale resolution and minimal trauma. A novel rotational coupler with a glass capillary tube is also presented that couples light from a rotating single-mode fiber to a stationary one. A prototype needle with a 27-gauge (approximately 410-microm) outer diameter has been developed and is demonstrated for in vivo imaging. The OCT needle can be integrated with standard excisional biopsy devices and used for OCT-guided biopsy.

Intraepidermal expression of basement membrane components in the lesional skin of a patient with dystrophic epidermolysis bullosa

The patient was a 15-year-old male. Since birth, he had developed blistering and erosion of the skin. Biopsy skin specimen of the bullous lesions showed subepidermal blister formation. Electron microscopic examination revealed that tissue separation had occurred at the sublamina densa level. By indirect immunofluorescence using antibodies specific for alpha 6 integrin, laminin 5, type IV collagen, and type VII collagen, all of these basement membrane components were detected as coarse granular intracytoplasmic deposits only in the basal and suprabasal cells of the blister roof. In the non-blistered regions, these basement membrane components showed a linear pattern similar to that seen in normal skin. These findings suggest that intraepidermal expression of basement membrane components was closely related to the blister formation. The biological meaning of intraepidermal expression of basement membrane components were also discussed.

Operational improvement of gynecologic laparoscopic operating room services: an internal review

BACKGROUND

To reorganize reusable laparoscopic instrumentation to promote instrument accessibility, minimize instrument breakage, eliminate infrequently used instruments on permanent trays, and help control maintenance costs.

TECHNIQUE

The Robert Wood Johnson University Hospital Gynecologic Steering Committee evaluated during a 5-month period the storage, use, and maintenance of gynecologic laparoscopic instrument sets used in the surgical suite. Acting on this data, the committee oversaw the following changes. Infrequently used instruments were removed from permanent trays and separately packaged. Two types of gynecologic laparoscopy trays were prepared: one for laparoscopic bilateral tubal ligations and one for both diagnostic and operative laparoscopy. A double-decker compartmentalized tray in which instruments were sterilized and stored replaced the extant single-layer ones in which instruments were stacked on each other. To facilitate instrument identification and function, a surgical manual was compiled with photographs of each instrument and a description of its use.

EXPERIENCE

After implementation of these changes, maintenance and sterilization costs for a 10-month period were compared with those for the previous 10 months. There was a savings of $13,889. The ratio of total costs divided by number of cases performed during the two study periods was also compared. There was a savings of $31 per case.

CONCLUSION

Savings were achieved by reorganizing this operating room's handling of reusable gynecologic laparoscopy equipment. By eliminating infrequently used instruments from the permanent trays and by using a double decker compartmentalized tray that was used during surgery, sterilization, and storage, both sterilization costs and maintenance costs were reduced.

Lymphoepithelioma-like carcinoma of the skin

We report a case of lymphoepithelioma-like carcinoma of the skin on the right cheek of a 67-year-old man. Histologically, the entire dermis was occupied by multiple lobules of atypical epithelial tumor cell nests surrounded by inflammatory cells. Immunohistochemical examination showed that the epithelial tumor cells were positive for cytokeratin and epithelial membrane antigen. The inflammatory cells were positive for leukocyte common antigen and T-cell marker. Among the tumor nests, small ductal structures were positive for carcinoembryonic antigen. Ultrastructurally, these epithelial tumor cells had well-developed desmosomes and were joined to each other; no tonofilaments were observed in the cytoplasm. These findings strongly suggest that these tumor cells tended to differentiate to the adnexa of the skin.

Bullous pemphigoid associated with internal malignancies: identification of 180-kDa antigen by western immunoblotting

We report three cases of bullous pemphigoid associated with internal malignancies. Two cases were associated with gastric cancer and one with rectal cancer. Immunoblot analysis, using epidermal extract of normal human skin, revealed that these patients' sera reacted only with bullous pemphigoid antigen with a molecular weight of 180 kDa (BP180). The relationship of BP180 to malignant tumours is discussed.

[Pit fall of aprotinin administration during open heart surgery]

Aprotinin administration during open heart surgery has been attempted at various institutions to reduce hemorrhage and improve the rate of no-transfusion operations, and has been reported to be effective. The treatment has been effective also in the 45 patients operated on at our institution. However, we experienced LOS at weaning from extracorporeal circulation (8 cases) considered to be due to aprotinin administration, suggesting unexpected risk of the treatment. Evaluation was made by classifying the patients according to the aprotinin dose; A high-dose group administered aprotinin at 300 x 10(4) units (20 patients), a low-dose group administered aprotinin at 100 x 10(4) units (8 patients), and a control group not administered aprotinin (15 patients). The volume of postoperative hemorrhage increased with the dose of aprotinin, and was significantly lower in the high dose and medium-dose groups than in the control group, but was not significantly different in the low-dose group. The postoperative peak CPK and CPK-MB were not significantly differ but increased slightly with the aprotinin dose. Probably for this reason, IABP was needed in 8 (17.8%) of the 45 patients because of LOS at weaning from extracorporeal circuration. A diagnosis of perioperative myocardial infarction (PMI) was made in 7 of these patients. Factors other than aprotinin are unlikely to be the cause of LOS, and the condition is considered to have been induced by micro-embolism during extracorporeal circulation with aprotinin administration. We propose two points as basis for this speculation. The first is that the body temperature during extracorporeal circuration, which was 30-35 degrees C in the bladder, promoted antifibrinolytic activity of aprotinin. The second is poor control of ACT during extra corporeal circulation. Thus, we suggest the risk of the use of aprotinin without further reduction in the body temperature during extracorporeal circuration. At present avoidance of high body temperatures and strict control of ACT during extracorporeal circulation are important preventive measures against micro-embolism possibly caused by aprotinin.

Pemphigus vulgaris exacerbated by exposure to sunlight

We report two cases of pemphigus vulgaris who showed exacerbation of their bullous skin lesions after exposure to sunlight. These cases indicate that ultraviolet light is an aggravating factor, not only for pemphigus foliaceus, but also for pemphigus vulgaris.

Trichilemmal carcinoma developing in a burn scar: a report of two cases

Two cases of trichilemmal carcinoma (TLC) developing in burn scars are reported. In Case 1, a 73-year-old man developed a TLC on his left lower leg five years after a burn. In Case 2, a 43-year-old man developed a cauliflower-like mass on his head 42 years after a burn. Histologically, tumor cells showed a lobular proliferation in continuity with the epidermis. Tumor nests were mostly composed of large atypical cells with clear cytoplasms containing PAS-positive, diastase sensitive materials. Some of the nests showed trichilemmal-type keratinization. These cases were treated only with surgical excision, and there has been no evidence since of local recurrence or metastasis.

Distribution of lectin UEA-I in trichilemmal carcinoma, squamous cell carcinoma, and other epithelial tumors of the skin

Trichilemmal carcinoma (TLC) is a cutaneous appendage tumor. In some cases, the histological distinction between TLC and squamous cell carcinoma (SCC) is difficult with hematoxylin & eosin staining. In the present study, in order to establish a simple and reliable method for distinguishing between TLC and SCC, we examined the lectin Ulex europaeus agglutinin-I (UEA-I)-binding patterns of TLC (4 cases), SCC (10 cases), malignant proliferating trichilemmal cyst (MPTC) (3 cases), Bowen's disease (4 cases), Bowen's carcinoma (4 cases), actinic keratosis (4 cases), basal cell carcinoma (8 cases), and eccrine porocarcinoma (1 case). In normal skin samples, UEA-I was strongly positive in the outer root sheath cells of the hair follicle and weakly positive in the granular layers of the epidermis. UEA-I stained the tumor cells of TLC clearly and some MPTC and Bowen's disease cells weakly. This result indicates that histochemical staining with UEA-I is a simple and useful method for distinguishing between TLC and SCC of the skin.

Cloning and analysis of the alternative oxidase gene of Neurospora crassa

Mitochondria of Neurospora crassa contain a cyanide-resistant alternative respiratory pathway in addition to the cytochrome pathway. The alternative oxidase is present only when electron flow through the cytochrome chain is restricted. Both genomic and cDNA copies for the alternative oxidase gene have been isolated and analyzed. The sequence of the predicted protein is homologous to that of other species. The mRNA for the alternative oxidase is scarce in wild-type cultures grown under normal conditions, but it is abundant in cultures grown in the presence of chloramphenicol, an inhibitor of mitochondrial protein synthesis, or in mutants deficient in mitochondrial cytochromes. Thus, induction of alternative oxidase appears to be at the transcriptional level. Restriction fragment length polymorphism mapping of the isolated gene demonstrated that it is located in a position corresponding to the aod-1 locus. Sequence analysis of mutant aod-1 alleles reveals mutations affecting the coding sequence of the alternative oxidase. The level of aod-1 mRNA in an aod-2 mutant strain that had been grown in the presence of chloramphenicol was reduced several fold relative to wild-type, supporting the hypothesis that the product of aod-2 is required for optimal expression of aod-1.

[Re-replacement of Starr-Edwards mitral valve (model 6320) for prosthetic valve endocarditis 22 years after replacement]

The patient was a 43-year-old woman who had undergone mitral valve replacement with Starr-Edwards ball valve (model 6320) 22 years ago. Perivalvular mitral leakage due to prosthetic valve endocarditis and tricuspid regurgitation were found. She underwent re-replacement of the mitral valve. The operative findings revealed almost intact valvular function of the ball valve. As far as we know, 22 years is the longest follow-up for the Starr-Edwards ball valve which has maintained normal function.

Role of sodium pump activity in warm induction of cardioplegia combined with reperfusion of oxygenated cardioplegic solution

Na+/K+ adenosinetriphosphatase (sodium pump) may play a key role in the prevention of reperfusion injury caused by Ca2+ overload. The present study was undertaken to investigate the role of sodium pump activity in warm induction of cardioplegia combined with reperfusion of oxygenated cardioplegic solution. Isolated and perfused rat hearts were subjected to 15 minutes of normothermic ischemia to produce a model of severely failing heart. The hearts then received myocardial preservation. Warm (37 degrees C) or cold (4 degrees C) oxygenated modified St. Thomas' Hospital solution was given for 5 minutes before and after 120 minutes of hypothermic cardioplegic arrest. Reduced myocardial pH during normothermic ischemia was adjusted toward the baseline level by administration of cold or warm oxygenated cardioplegic solution without a significant intergroup difference. Myocardial adenosine triphosphate levels decreased to less than 30% of the preischemic level during 15 minutes of normothermic ischemia, but were increased partly by induction of cold or warm oxygenated cardioplegia. Thus these metabolic indices failed to demonstrate the superiority of warm over cold oxygenated cardioplegia. Na+/K+ adenosinetriphosphatase activity in the membrane fraction was significantly stimulated by a cardioplegic dose of K+ with maximum activity at 16 mEq/L. The enzyme activity of the heart measured after normothermic ischemia was reduced to less than 50% of that in the nonischemic heart. Although warm induction of cardioplegia and reperfusion of oxygenated cardioplegic solution maintained Na+/K+ adenosinetriphosphatase activity at the preischemic level, the enzyme activity was abolished at 4 degrees C, which is the temperature used in cold cardioplegia. A subtoxic dose of ouabain (0.1 mmol/L) inhibited the enzyme activity of the heart undergoing this preservation regimen to approximately 50%. Warm induction and reperfusion of oxygenated cardioplegic solution showed significantly better recovery of isovolumic left ventricular function during reperfusion compared with that obtained with cold oxygenated cardioplegia. However, the beneficial effect of warm oxygenated cardioplegia on left ventricular function was compromised by inclusion of 0.1 mmol/L ouabain without a significant effect on myocardial metabolic parameters. These results suggest that stimulation of Na+ pump activity may account for the beneficial effect of warm induction and reperfusion of oxygenated cardioplegic solution in the energy-depleted heart.

[Modified David's operation for aortic regurgitation associated with annulo-aortic ectasia]

Composite graft replacement of the ascending aorta and aortic valve has been indicated for aortic regurgitation (AR) associated with annulo aortic ectasia (AAE). 29-year-old female with AR due to AAE associated with Marfan's syndrome underwent the replacement of ascending aorta by sparing an aortic valve with good result. Under cardiopulmonary bypass, the proximal ascending aorta was dissected circumferentially down to the ventriculo-aortic junction. The aneurysmal aorta and the all three sinuses of valsalva were excised, leaving 7 mm of arterial wall attached to the aortic valve and small buttons of arterial wall around the both left and right coronary arteries. The aortic valve was reimplanted inside a 28 mm Dacron graft which was calculated by aortic valve leaflet height. The left coronary artery was reimplanted to the graft by interposing a short 10 mm Dacron graft between coronary ostia and graft and the right coronary artery was anastomosed directly to the graft (Piehler's procedure). We called these procedure "modified David's operation". The patient has survived the operative procedure without any complications. Postoperative aortogram showed a competent aortic valve and the peak systolic pressure gradient across the aortic valve was 20 mmHg. We believe this new procedure preserving the native aortic valve is useful for preventing from some complications associated with artificial heart valves.

[Quadruple coronary artery bypass grafting with arterial grafts--application of internal thoracic artery and right gastroepiploic artery]

Arterial graft has been widely applied for coronary artery bypass because of its excellent long-term patency. However, when more than four coronary bypass graftings should be carried out using internal thoracic arteries (ITAs) and right gastroepiploic artery (GEA), some surgical techniques must be devised. We performed quadruple coronary artery bypass grafting using three arterial grafts; bilateral ITAs and GEA, and obtained good results. We used free RITA graft for sequential grafting in one case. In another case, GEA was divided into two segments and used as two free grafts. From our experience, we believe it is possible to perform multiple coronary revascularization using only arterial grafts with one median skin incision.

[Free arterial graft for coronary bypass grafting]

Free arterial grafts were aggressively placed in 39 patients (1991 to 1993). There were 34 males and 5 females, and mean age was 59.9 year old. Of 85 arterial grafts, 41 were free grafts, and their materials included left and right internal thoracic artery (LITA, RITA) and right gastroepiploic artery (GEA). There were one free LITA-left anterior descending coronary artery (LAD), seven free RITA-LAD, three free RITA-diagonal branch (Dx), 14 free RITA-left circumflex coronary artery (LCX), 10 free RITA-right coronary artery (RCA), two sequential RITA-Dx-LCX, one free GEA-Dx, two free GEA-LCX, and one free GEA-RCA bypass. Of 41 free arterial grafts, 38 were in the aorta-coronary position, and the proximal anastomosis was constructed first under single aortic cross-clamping to get the larger anastomotic sites for both at the proximal and distal ends of the arterial graft. The proximal sites of the remaining 3 arterial grafts were placed to concomitantly utilized saphenous vein grafts in two patients and RCA in one patient because of their shortness. Perioperative complications included no exploration for bleeding, myocardial infarction in one (2.6%), intra-aortic balloon pumping in three (7.7%), and wound complications in two (5.1%). 28 cases (72%) were completely revascularized with only arterial grafts. Of 41 free arterial grafts studied within one month after operation, all grafts were patent. All patients were free from angina after a 27 months mean follow-up. We believe that the proximal anastomosis technique for free arterial graft we used could be acceptable alternative for many surgeons. These excellent results justify wider use of free arterial grafts.